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UNITED STATES OF AMERICA. 



A TREATISE ON DISEASES 



OF THE 



RECTUM, ANUS, AND 
SIGMOID FLEXURE 



/by 



JOSEPH M. MATHEWS, M. D. 

PROFESSOR OF PRINCIPLES AND PRACTICE OF SURGERY, AND 

CLINICAL LECTURER ON DISEASES OF THE RECTUM, KENTUCKY SCHOOL OF MEDICINE 

VISITING SURGEON STS. MARY AND ELIZABETH HOSPITAL 

CONSULTING SURGEON LOUISVILLE CITY HOSPITAL 

CONSULTING SURGEON JENNIE CASSADAY FREE INFIRMARY FOR WOMEN 

LATE PRESIDENT MISSISSIPPI VALLEY MEDICAL ASSOCIATION 

PRESIDENT LOUISVILLE CLINICAL SOCIETY ; VICE-PRESIDENT LOUISVILLE SURGICAL SOCIETY 

MEMBER INTERNATIONAL MEDICAL CONGRESS, AMERICAN MEDICAL ASSOCIATION, 

SOUTHERN SURGICAL AND GYNAECOLOGICAL SOCIETY, 

KENTUCKY STATE MEDICAL SOCIETY, STATE BOARD OF HEALTH OF KENTUCKY 

ORATOR OF THE AMERICAN MEDICAL ASSOCIATION ON SURGERY, 1891, ETC. 



WITH SIX CHROMO-LITHO GRAPHS AND 
NUMEROUS ILLUSTRATIONS 



OCT 26 1892 






NEW YORK 
D. APPLETON AND COMPANY 

1892 



c£>* 



9> f 



Copyright, 1892, 
By D. APPLETON AND COMPANY. 



Electrotyped and Printed 
at the Appleton Press, U. S. A. 



TO 

MY COLLEAGUES OF THE MEDICAL PROFESSION 

WHO HAVE AIDED AND ENCOURAGED MY EFFORTS 

TO ADVANCE THE SCIENCE AND ELEVATE THE PRACTICE OF 

RECTAL SURGERY, 

THIS WORK IS INSCRIBED BY THE AUTHOR. 



PKEFACE. 



I have written this book because of a desire to record my 
individual experience of fifteen years as a rectal specialist, 
in answer to the demand of my students and friends. Dur- 
ing this time I have learned that many things that are taught 
are not true, and that many true things have not been taught. 
I have therefore not taken other men's opinions as my guide, 
but have accepted as truths only those things which could be 
substantiated by fact, and here recorded them. In differing 
from others on any special point I have tried first to state 
fairly and fully their views, and then my own. The verdict 
is left to the reader. I have introduced several chapters 
which are new to books on this subject. Among these will 
be found the following : Disease in the Sigmoid Flexure, 
The Hysterical or Nervous Rectum, Anatomy of the Rec- 
tum in Relation to the Reflexes, Antiseptics in Rectal 
Surgery, A New Operation for Fistula in Ano. I have 
styled the book A Treatise on Diseases of the Rectum, 
Anus, and Sigmoid Flexure. In embracing the sigmoid 
flexure in the caption, I do so because I have become con- 
vinced of its great importance as a seat of disease, and the 
utter lack of attention which it receives. From all time it 
has been recognized that serious pathological changes take 
place in it, but the works are singularly silent as to how to 
treat it when diseased. The chapter on The Hysterical or 
Nervous Rectum is embraced mainly to give my reasons for 
opposing some views of the learned and distinguished Prof. 
Groodell. The chapter on the Anatomy of the Rectum in 
Relation to the Reflexes is made to follow that of The Hys- 



Vi DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

terical Rectum in order to account for some vague affec- 
tions of the lower bowel. The subject of the " reflexes" 
is one of the most important before the profession to- day 
The chapter on Antiseptics in Rectal Surgery is inserted to 
demonstrate that such precautions can be practiced in this 
line of work. A New Operation for Fistula in Ano refers 
to my method of treating the disease by afistulotome. Al- 
though several have claimed the introduction of this little 
instrument, the dates, I am sure, will give me priority. I am 
greatly indebted to the following firms for cuts of instru- 
ments, which has enabled me to give so clear a demonstration 
of what a surgeon needs in doing rectal work, viz. : Messrs. 
John Reynders & Co., New York ; Messrs. Truax, Green & Co., 
Chicago ; Messrs. William Armstrong & Co., Indianapolis ; 
Messrs. Connable & Harper, Xenia, Ohio ; The Nedofik Manu- 
facturing Company, Wyeth City, Ala. To Dr. Paul Kempf, 
and to Dr. Henry Macdonald, artist for the publishers, I 
am especially indebted for the colored drawings which ap- 
pear in the book. To the publishers, Messrs. D. Appleton & 
Co., I wish to return my sincere thanks for the many cour- 
tesies that they have extended me, and for the elegant and 
artistic manner in which the book appears. 

Louisville, Ky. 



DIFFERENTIAL DIAGNOSIS OF DISEASES OF THE RECTUM, yii 



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v iii DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



Signs without 
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DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



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TABLE OF CONTENTS. 



CHAPTER I. 

PAGE 

Introductory. — Rules to be observed in examination, diagnosis, etc. — Diag- 
nosis. — Examination. — The rectal sound. — The hand. — A case. — Rectal 
examination in relation to life insurance. — Illustrative cases ... 1 

• 

CHAPTER II. 

Anatomy of the rectum. — Shape and relations. — Relations. — Surgical impor- 
tance. — Muscular coat. — Submucous coat. — Mucous membrane. — Folds of 
the rectum. — Their use. — Pockets and papillae. — External sphincter mus- 
cle. — Internal sphincter. — Levator ani. — Recto -coccygeus. — Transversus 
perinei. — Blood-supply of the rectum 33 

CHAPTER III. 

Constipation. — Importance of, to the rectal surgeon. — Effects of. — Causes of. — 
The third sphincter. — Physiology of evacuation. — Treatment. — Result of 
impactions 44 

CHAPTER IV. 

Antiseptics in rectal surgery. — Aseptic operation. — Disinfection. — (a) Disinfec- 
tion of all persons engaged about the operation. — (b) Disinfection of the 
operative region. — (c) Disinfection of the instruments. — (d) Disinfection of 
the sponges. — (e) Disinfection of the wound. — Antiseptic operation. — Dis- 
infection as in aseptic operations. — Operations on the rectum under 
whisky. — Cases. — Local anaesthesia. — Chloroform and ether . . .80 

' CHAPTER V. 

Haemorrhoids. — Description. — External haemorrhoids. — Symptoms. — Cases. — 
Treatment 95 



CHAPTER VI. 

Internal haemorrhoids. — Description. — Location. — Cases. — Haemorrhage in. — 
Complications. — Cases. — Symptoms. — Diagnosis. — Treatment. — Local ap- 
plications. — Operations for internal haemorrhoids. — Methods. — Injections 
of carbolic acid. — Cases. — Crushing. — Clamp and cautery. — Excision. — 
Dilatation of the sphincter muscle. — Whitehead's operation. — Objec- 
tions to 109 



xii DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

CHAPTER VII. 

The ligature in the treatment of internal haemorrhoids. — Preparation of the 
patient. — Dressings. — Case. — After - treatment. — Complications. — Case. — 
Haemorrhage following operations for internal haemorrhoids. — Case. — 
Causes of haemorrhage. — Tamponing the rectum 158 

CHAPTER VIII. 

Fistula in ano. — Case. — Causes. — Cases. — Abscesses as causes of. — Case. — Va- 
rieties of fistula. — Cases. — Complete fistula. — Blind external fistula. — 
Cases. — Blind internal fistula. — Horseshoe fistula. — The relation of fistula 
in ano to phthisis. — Fistula as a derivative .179 

CHAPTER IX. 

Treatment of fistula in ano. — The fistulatome. — Cases. — The operation for 
fistula in ano by the knife. — Case. — Method. — Cases. — Treatment of fistula 
by ligature. — Advantages of the ligature. — Treatment of horseshoe fistula. 
— Case. — After-treatment for fistula 209 

CHAPTER X. 

The nervous or hysterical rectum. — Power of the reflexes. — Cases. — Obscure 
diseases of the rectum. — Case. — JEtiology. — Case 242 

CHAPTER XI. 
Neuralgia of the rectum. — Cases. — Treatment 260 

CHAPTER XII. 

Irritable ulcer or fissure. — Pain in. — Cases. — Examination and Diagnosis. — 
Symptoms. — Cases. — Treatment. — Palliative. — Operation. — Division of the 
Sphincter. — Dilatation 267 

CHAPTER XIII. 

The anatomy of the rectum in relation to the reflexes. — Importance of the 
subject. — Physiology of the reflexes. — Cases. — Conditions essential for re- 
flex acts. — Cases illustrating varieties of manifestation .... 289 

CHAPTER XIV. 

Ulceration of the rectum. — Case. — Varieties. — Inflammation quickly followed 
by ulceration. — Influence of tuberculous diathesis. — Cases. — Scrofula. — 
Dysentery. — Treatment. — Ulceration from foreign bodies. — Case . . 318 

CHAPTER XV. 

Non-malignant stricture of the rectum. — ^Etiology. — Congenital. — Acquired. 
— Spasmodic. — Dysenteric. — Tubercular. — Inflammatory. — Traumatic. — 
Venereal.— Diagnosis. — Symptoms. — Treatment. — Dilatation. — Incision. — 
Electrolytic. — Instruments. — Method of applying.— Excision. — Colotomy . 336 



TABLE OF CONTENTS. xiii 

CHAPTER XVI. 

Cancer of the rectum. — Hereditary tendencies. — Case. — Diagnosis. — Method of 
diagnosticating cancer of the rectum. — Classification. — Symptoms. — Cases . 366 

CHAPTER XVII. 

Treatment of cancer of the rectum. — Colotomy. — Risk of life. — Method of 
operating. — Manner of doing the inguinal operation. — The author's meth- 
od. — Condition of the patient after operation. — Method of doing lumbar 
colotomy 383 

CHAPTER XVIII. 

Extirpation and palliative treatment of cancer. — Cases. — Mortality. — Plan of 
operation. — Cases ............ 407 

CHAPTER XIX. 

Disease of the sigmoid flexure. — Cases. — Pathological conditions. — Conges- 
tion. — Inflammation. — Simple ulceration. — Specific ulceration. — Treat- 
ment. — Cancer. — Symptoms. — Prognosis. — Extirpation. — Syphilis in the 
sigmoid flexure. — Treatment. — Foreign bodies in the sigmoid flexure. — 
Volvulus of the sigmoid flexure . ... .. . . . .. .427 

CHAPTER XX. 

Prolapsus ani. — Case. — Diagnosis. — Treatment. — Cases. — Operation . . . 467 

CHAPTER XXI. 

Pruritus ani. — iEtiology. — Symptoms. — Treatment .,«„.. 493 

CHAPTER XXIL 
Impacted faeces. — Case. — Treatment . 506 

CHAPTER XXIII. 
Villous tumor of the rectum. — Cases 514 

CHAPTER XXIV. 

Malformations of the rectum and anus. — Congenital malformations of the anus. 
— Malformations of the rectum. — Symptoms. — Prognosis. — Treatment . 518 



LIST OF ILLUSTRATIONS. 



Plate I. — Operation for haemorrhoids by clamp and cautery . . facing 100 



II. — Operation for internal haemorrhoids by ligature 
III. — Operation for fistula in ano by Mathews's fistulotome 
IV. — Operation for fistula in ano by the knife . 

V. — Operation for fistula in ano by the elastic ligature . 
VI. — Prolapsus ani (Mathews) 



164 
212 
224 
232 
469 



The Nedofik sofa as a piece of furniture 12 

Position for rectal examination 13 

Second position for rectal examination 13 

Favorable position for operations upon the rectum 14 

Illuminating lamp 14 

Parabolic metallic reflector 15 

Connable and Harper battery . . 16 

Flexible stem for electric light 16 

Examination of the rectum by electric light 17 

Speculum open at side .20 

Allingham's fenestrated speculum 20 

Kelsey's rectal speculum 20 

Cook's tubular speculum 20 

Green's fenestrated speculum 20 

Tiemann's rectal speculum 21 

Mathews's self-retaining rectal speculum 21 

Wales's rectal bougie 22 

Collin's lamp 128 

Candle-holder with reflector 128 

Trousseau's pile-supporter 132 

Metal pile plug 132 

Prolapsus ani supporter 132 

Pile-supporter, elastic 133 

Hard-rubber pile pipe 134 

Hutchinson's ointment syringe 135 

Nott's rectilinear ecraseur 144 

Lamp for heating cautery irons 145 

Paquelin's thermo-cautery 146 

Mathews's pile-forceps 147 

Smith's clamp 147 

Bush's pile-forceps 147 

Ashton's pile clamp-forceps 148 

Benham's pile-clamp 148 

Thebaud's sphincter dilator 149 



xvi DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

PAGE 

Collin's dilator 150 

Sims's dilator 151 

Durham's dilator 151 

Rigaud's dilator 151 

Curved pile-scissors 153 

Mathews's fistulotome 213 

Bush's needle-holder 217 

Needles in handle 218 

Rectal probes 222 

Grooved director . . . ■ . 222 

Gowlland's director 223 

Electric light and cautery in case 226 

Thermo-cautery ready for use 227 

Allingham's ligature carrier 236 

Nervous supply of anus (Hilton) . . . 268 

Nervous relations of irritable ulcer of anus (Hilton) 293 

Non-malignant stricture of rectum . 343 

Divulser for stricture of rectum 355 

Dilator for stricture of rectum 356 

Prince's obturator 358 

Cripps's line for inguinal colotomy 395 

Inguinal colotomy (Mathews) 401 

Inguinal colotomy (Cripps) 402 

Lumbar colotomy 404 

Sarcomatous infiltration of rectum 408 

Excision of rectum (Allingham) 415 

Satchel for rectal instruments 486 

Scoop for removal of faeces 508 

A rectal irrigator 510 

Villous tumor (Cook) 516 



V. 



DISEASES OF THE 
RECTUM, ANUS, AND SIGMOID FLEXURE. 



CHAPTER I. 

INTRODUCTORY. 

It is a well-recognized fact that diseases of the rectum 
have not received that careful attention of the medical pro- 
fession which their importance demands. Other portions of 
the body have received a greater consideration, and yet are 
of no more importance. From time immemorial diseases of 
the rectum have been in the hands of the charlatan. In the 
last decade or two the profession, both in this country and in 
Europe, has given these diseases more serious attention than 
heretofore. In 1877 I first conceived the idea of making dis- 
eases of the rectum a special study. Having been engaged in 
general practice for a number of years, I had noticed that 
patients suffering from any one of these diseases received but 
very little attention or consolation from the general prac- 
titioner, and I fell into the usual routine practice, which 
allowed the patient to make his or her own diagnosis, and 
prescribed accordingly. It was not long before I discovered 
that these patients failed to return to me for advice, and the 
next heard of them was that they were in the hands of the 
advertising man. Recognizing, as I did, the importance of 
these diseases, I determined to investigate, as far I could, and 
to ascertain from my professional brethren to what extent 
rectal affections were observed and treated in their practice. 
It was a revelation to be informed that an examination was 

seldom made, and that the prescription given was nearly uni- 
1 



2 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

versally the same. It being a fact that no examination was 
made, the patient invariably diagnosticated piles as the affec- 
tion, received some astringent ointment, and was told to report 
again. This, as I have intimated, was seldom done ; for the 
reason, I take it, that very little, if any, benefit accrued to 
the patient. I then determined, in view of the fact that a 
vast number of people were affected with these diseases, and 
that their importance could not be overestimated, to seek fur- 
ther for information and for study in this special line. In a 
few months thereafter I gave up my general -practice and 
went to London, that I might see the admirable work at St. 
Mark's Hospital, it being the only hospital in the world de- 
voted exclusively to diseases of the rectum. In this connec- 
tion I desire to say that I am deeply indebted and obligated 
to Mr. William Allingham, the senior surgeon of that insti- 
tution, for the many courtesies shown me while there. Upon 
my return to Louisville I entered this new field as a special- 
ist. At that time there was no surgeon in the United States 
treating these diseases as a specialty. I allude, of course, to 
men in the regular profession. In nearly every large city 
of the Union some were advertising to cure rectal diseases. 
By their peculiar methods they were ostracized from the 
medical profession : consequently, if any serious accident or 
complication followed their treatment, no consultation could 
be held with competent physicians, and the patient had to 
suffer the consequences. Fortunately, however, the adver- 
tisers generally recognized their own incompetency and did 
very little surgery on these parts. Indeed, from that day to 
this they have been in the habit of saying that they perform 
each and all of these operations without the aid of the knife. 
But since these diseases have taken rank in importance with 
disease in other portions of the body, many men, distin- 
guished as able and competent surgeons, have given them the 
attention that their importance demands, and to-day they are 
written about in all medical journals, embraced in the text- 
books, and discussed before all regular medical organizations. 
Some special works have been published in the last few 



INTRODUCTORY. 3 

years in America, notably by Kelsey, Andrews, and Agnew, 
and the profession at large is being educated to the fact that 
no portion of the human anatomy is of any more importance 
in disease than the rectum. It is with some pride, there- 
fore, that I say that, up to the time mentioned, no one in the 
United States had made a specialty of these diseases, and 
upon a close inquiry into the facts I could not ascertain that 
any one in Europe had done so. Therefore, in claiming to be 
a pioneer in this special branch of surgery as a specialist, it 
affords me satisfaction to know that these diseases have as- 
sumed the importance that they have, and that to-day dis- 
eases of the rectum, as a specialty, rank alongside of the 
other legitimate specialties in medicine and surgery. As my 
experience grew larger as a specialist, I took occasion, when- 
ever the opportunity permitted, to discuss the special subject 
and to write often for the medical press. Now, at the end of 
fifteen years' constant pursuit in this line, and after twelve 
years as a teacher in this special branch, I have yielded to 
the solicitation of my friends and the flattering request from 
my students to publish a work on these diseases. It will 
be found to be more or less a recital of my individual experi- 
ence in this field. I shall take occasion to speak plainly 
what I think, and if I differ from the authorities who have 
written before me, on important questions, I beg to say that 
it is simply because I believe in the truth of what I am say- 
ing. I shall try to argue the case in many instances with 
those who differ from me, and hope not to appear dogmatic ; 
but in those instances where my experience has taught me 
that I am correct, I shall try to defend my position. I shall 
quote from comparatively few authors, and shall give no 
foot-notes. I have often thought that works designed for 
the busy practitioner should, as far as possible, be exempt 
from all such things, and, as this work is especially intended 
for the student and general practitioner, I shall aim to make 
it as practical as possible. The etiology of disease I shall 
make second to the manner of dealing with the disease, for 
the reason especially that a diagnosis can be arrived at in 



4: DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

all these cases best by the author's giving a clear recital of 
the clinical history, and by an ocular inspection to be made 
by the physician. In a word, then, this book shall contain 
an individual opinion in each and every case. 

Rules to be observed in Examination, Diagnosis, etc. — Any one 
who has been in general practice, even for a short time, 
has been made to know that rectal diseases are very com- 
mon. Any one afflicted in this manner has only to mention 
the fact, and he will have many to come to his comfort 
by telling of a like affliction. It is very true that .the vast 
majority of patients call any and all affections in these 
parts piles, and so term them in talking to their friends and 
in consulting their physicians. But the truth of this state- 
ment confirms what I have said, that rectal diseases are as 
common as or more common than any other class of diseases 
to which the human body is heir. Some authors affirm that 
certain races of the earth are peculiarly exempt from these 
diseases. Van Buren mentions in his work that, having 
been much with the Indians in his early life, he could not 
recall a single instance where one of them was affected with 
rectal trouble. Taking this as a true statement, it would 
incline us to believe that an outdoor life, exercise, and a 
peculiar diet would militate against the affection, and yet, in 
my experience, I have seen the farm lad, who went to bed 
early and was early to rise, who observed perfectly regular 
habits, and was devoid of all vices, affected with this kind 
of trouble in the same way as his city cousin, who led an 
irregular life, ate and drank much, and was addicted to all 
those excesses which are said to be conducive to this state. 
I was inclined to think, a number of years ago, that those 
living in the extreme South would be more subject to this 
class of diseases than those living in a colder climate, as in 
the Eastern and Northern States of the Union, but my record- 
book will show an equal number of cases from each section, 
notwithstanding that I am as accessible to the one as to the 
other. We often say to patients that many of these diseases 
are preventable, and lay out for them a certain plan which 



INTRODUCTORY. 5 

relates to diet, exercise, habits, clothing, etc., and assure 
them that, if this be followed, there will be a certain immu- 
nity at least from these diseases ; and yet when you come to 
an actual observation, you may find that the man of sed- 
entary habits escapes these troubles, while the one who has 
pursued our advice is overtaken by them. The laboring man, 
who lives a frugal life, is as often attacked as his rich neigh- 
bor, who drives in his carriage to his bank. Some authori- 
ties say that men are more liable to certain rectal ailments 
than women, or vice versa. In my practice the difference 
has not been so well marked as to be worthy of notice. It is 
an every-day occurrence that we find ourselves telling our 
young lady patients that, if they persist in wearing fashion- 
able clothing — which often includes tight lacing — they will 
be the subjects of disease, and yet we are confronted by the 
fact that they are as exempt from these troubles as the girl 
who does not lace at all. Constantly we say to those who 
come to us for advice in regard to constipation that, unless 
it is overcome, it will breed rectal trouble ; and yet we are 
cognizant of the fact that many who suffer from persistent 
constipation have no rectal disease at all. So, in truth, each 
one of these cases must rest upon an individual considera- 
tion, and not be dealt with in a general way. Whereas, in 
times past, the patient has left the physician's office with 
some astringent ointment, from which he received no benefit, 
it can now be definitely said that of all diseases, whether 
medical or surgical, there is no class that yields so promptly 
to treatment as diseases of the rectum. Among the list are 
some of the most painful, distressing, and dangerous of all 
diseases, and yet, in the majority of cases, a radical cure can 
be promised if the patient will submit to an operation. 
Many persons have been incapacitated for months and even 
for years, suffering the most dreadful pain, caused by a sim- 
ple fissure of the anus which, when diagnosticated properly, 
succumbs at once to a gentle divulsion of the sphincter mus- 
cles. Others have suffered torture for years with protruding, 
ulcerated hemorrhoids, abiding by the advice of friends, and 



6 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

oftentimes of the family physician, not to have them oper- 
ated on, which can easily be cured in the shortest possible 
time, a radical relief being afforded. So I might go on and 
enumerate instances through this whole class of disease, but, 
as they are to be taken up separately and discussed, I will 
make this mention suffice. 

On the other hand, if through ignorance or bad advice 
these diseases are neglected, they not only become harass- 
ing, incapacitating the patient for all work, but perhaps en- 
dangering his life ; and that man is a humanitarian who 
thinks it well enough to advise his friend to consult a sur- 
geon early about these affections. Witness a patient suffering 
from haemorrhage from the rectum. He may have imbibed 
the idea from some old physician that the bleeding was salu- 
tary, when we know for a fact that many persons have lost 
their lives by such haemorrhage. The pale face, emaciated 
form, and enervated system are often seen as evidence of this 
condition. In my practice, upon divers occasions, I have 
known patients to lose from one to ten ounces of blood at 
one evacuation, and oftentimes without their knowledge, as, 
for instance, in the use of dark water-closets. It goes with- 
out saying that, if this condition of affairs were to go on 
without detection for any length of time, it might end in 
the death of the patient. And yet the remedy is a very sim- 
ple one. 

Diagnosis. — I believe that the most important thing con- 
nected with medicine or surgery is a correct diagnosis of the 
disease. Indeed, I believe that, if a practitioner of medicine 
has correctly diagnosticated the affection, he is very apt to be 
giving the right medicine. So I would impress upon my read- 
ers the absolute necessity of making a correct diagnosis of all 
rectal trouble. I would say that, without exception, this will 
require an examination of the patient. It is strange, but it is 
true, that women will readily submit to a uterine examina- 
tion who would strenuously oppose a rectal one ; and I have 
found many men who would suffer the inconvenience, at 
least, of rectal trouble before they would agree to be exam- 



INTRODUCTORY. 7 

ined for it. Be this as it may, the best advice that I can give 
is to refuse to treat a serious affection of the rectum at all, 
unless the patient consents to your decision. Less than this 
would do the patient no good, and would do you harm. A 
rectal case, nnder your observation and treatment, that is 
neither benefited nor cured, is a walking advertisement against 
yon. After you have done your full duty, according to your 
own opinion, if the cure is not absolute, you have the com- 
fort of your own conscience at least. I am well aware of the 
fact that those who have written about these diseases say 
that it is best to allow the patients to detail their own cases. 
My experience certainly does not coincide with this. So posi- 
tive am I that the history given by them will often mislead 
the surgeon, that I am in the habit of saying to patients that 
I want no recitation from them, but that I desire that they 
shall answer, with as few words as possible, the direct ques- 
tions that I shall ask. In the first place, as I have intimated, 
they start out with the wrong premise, in that the majority of 
them complain of piles, when this affection has nothing to do 
with the case. Again, they will state things and conditions as 
facts which do not exist ; as, for instance, a superfluous piece 
of skin around the anus, which has become enlarged by the 
inflammatory process, is described by them as a pile that has 
protruded, and they are in the habit of pushing it within the 
rectum. If we should take this statement as true, we would 
likely prescribe for internal haemorrhoids, by giving the pa- 
tient some suppository, when, if we were to examine, we 
would either cut the tag away or order an external applica- 
tion. Or, a patient gives you the history and symptoms of 
pruritus, and even by the closest questioning you would be 
unable to determine that a little fistulous opening was the 
cause of the itching. These are but a few examples which 
teach us the necessity of a direct questioning of the patient. 
Then, too, it takes great familiarity with these diseases to ply 
the questions properly. Experience often rebuts the testi- 
mony of the books, and a little familiarity in examining for 
these diseases teaches us what line of questioning is the best. 



8 DISEASES OF THE RECTUM, ANUS r AND SIGMOID FLEXURE. 

It is generally said that first of all in this line of disease you 
should ask the patient concerning pain. This is not my first 
question, but rather, Does the bowel protrude at stool? 
This question means a great deal to the rectal surgeon. As I 
have stated, the vast majority of patients come to you com- 
plaining of piles. This one question then will come very near 
diagnosticating, in this particular at least, this class of dis- 
ease ; for I maintain that internal haemorrhoids that do not 
protrude during the action of defecation will not of ten require 
a surgical operation. Therefore, if the patient denies protru- 
sion, we can safely say that he is not seriously, or even incon- 
veniently, afflicted with internal haemorrhoids ; nor, I might 
say, with polypi, for these growths usually protrude also at 
stool. Now, if they make mention of protrusion, and say that 
they have pain during the said protrusion, or in the act of 
defecation, then we can safely come to the conclusion that, if 
they have internal haemorrhoids, they are complicated with 
some other trouble — for the reason that haemorrhoidal tumors 
which have existed for any length of time, especially those 
that protrude, are not usually accompanied with pain. It is 
too commonly believed that pain is a prominent symptom of 
internal haemorrhoids, when, in fact, pain very seldom is 
manifested, except, as I have intimated, where there is a 
complication with some other trouble. Granting, then, that 
the next question that we should put to the patient is relative 
to pain, it is just as necessary to ascertain the character of 
the pain. First, does it exist at all times, or is it only con- 
nected with the act of defecation ; and if so, is it of a severe 
and lancinating character, or of a dull, aching disposition? 
Looking to the diagnosis of fissure, we would ask the patient 
if there is an interim between the act of defecation and the 
coming on of the pain. Then, again, it should be ascertained 
how long the pain lasts, and if the subsidence of it is positive. 
A question of great moment is that of haemorrhage, and yet 
what patients say is but little guide to the real amount of 
blood that is lost. They often exaggerate to such an extent 
that the surgeon is misled by their statements. A much 



INTRODUCTORY. 9 

better plan is for them to save the discharge and for the 
physician to see for himself, and to make his own estimate. 
It can be asked of the patient, if the blood comes alone or is 
mixed with the fecal mass ; or if it comes from him with a 
spurt, which would indicate an arterial haemorrhage. It is 
usual for us to inquire, after any discharge, its nature, etc. 
I have found this very unsatisfactory, for the reason that pa- 
tients can not tell the difference between mucus and pus, 
and yet it is of the greatest significance to the surgeon. Nor 
do they state correctly the amount that is lost, but often im- 
press the physician that it is enormous, when, in reality, it is 
but slight. I place no stress upon any answer that patients 
give as to the character of the fecal evacuation. It is a very 
common thing for them to speak of having bilious discharges, 
when, in truth, it is very difficult for the physician to tell, 
even by a close scrutiny, if the discharge be a bilious one. 
Another question that is often asked patients is relative to 
the size, form, etc., of evacuation. No confidence can be 
placed in their replies. I have known persons suffering from 
a close stricture of the rectum to say that they have had a 
free evacuation, and it is no uncommon thing for those suf- 
fering from impaction of faeces to say that they suffer with a 
diarrhoea. I presume that the commonest question of all that 
is usually put to the patient under these circumstances is, 
whether he suffers from constipation or not. No one knows 
better than the physician that constipation is a relative term 
that the answers of a patient can not simplify. So, as a mat- 
ter of fact, I put very few if any questions to patients com- 
ing to me for advice in rectal trouble. I certainly think that, 
if these questions relative to the local symptoms are to be 
asked, it should be after an examination of the patient, and 
not before. A few questions, however, as to the general 
health should be asked, and, as it is believed by some that 
heredity plays a part in a tendency to rectal disease, some 
questions relative to the health history of the parents would 
be necessary. I do not wish to be understood as saying that 
I would ask the patient if his father or mother suffered from 



10 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

piles, or fissure, or polypi, or ulceration, etc., of the rectum ; 
but I mean to say that I would ask if they had any lung dis- 
ease, or liver disease, or perhaps cancer ; for I do not believe 
that any disease of the rectum is, in the strict meaning of the 
term, hereditary. Then the general health of the patient is 
to be inquired after ; whether he has ever had syphilis, or 
has a cough, or any kidney trouble. Indeed, every organ in 
the body should be carefully looked after, to aid us not only 
in making a correct diagnosis of rectal trouble, but also in 
determining whether an operation is admissible. I wish to 
state here, however, that the rectal disease may be of such 
character in regard to pain, inconvenience, etc., that an op- 
eration will be necessary, whether organic disease exists or 
not. I have operated upon patients for rectal trouble who 
were suffering from organic heart disease, upon others who 
had liver trouble, and upon a few who were affected with 
pronounced Bright's disease. The circumstances warranted 
the operation ; and, above all, I wish to emphasize that, if a 
uterine disease exists, I care not what the form may be, if 
rectal disease is coincident and is causing distress, an opera- 
tion for the latter should be performed. 

It is a recognized fact that a person can bleed to death 
from a small capillary pile. This being true, it would be lit- 
tle less than criminal for the surgeon to wait until his debili- 
tated patient was "built up," to secure and tie the bleeding 
vessel. I wish to be very plain and positive in speaking of 
this class, from the fact that I have seen quite a number of 
cases where the haemorrhage from the rectum was pulling the 
man down and endangering his life, and physicians had ad- 
vised that he let it alone until he was in a better state of 
health. Had he heeded such advice he would have gone to 
the grave. Of these cases I will have more to say in the chap- 
ter relating to haemorrhage from the rectum. There are some 
special questions that should be asked the patient, according 
to the sex. The subject of the reflexes is receiving very 
prominent and important consideration to-day. There is no 
portion of the body, anatomically considered, that has greater 



INTRODUCTORY. H 

reflex power than the rectum. Hence, if the patient be a 
woman, she should be asked if she has ever been treated for 
womb trouble. I put the question in this way rather than 
ask. her if she has womb trouble, for it may be that the rectal 
condition is exciting pain or distress in the uterus or ovaries. 
I think it quite a good idea for the rectal surgeon, who has a 
patient in whom he suspects uterine complication, to have the 
woman examined by a competent gynaecologist ; but I can 
not agree with Mr. Allingham when he says that the womb 
trouble must be first rectified, and the rectal condition treated 
afterward. In a great number of instances gynecologists 
have referred women patients to me for rectal treatment who 
were suffering at the same time with some local womb trouble 
which did not and would not yield to treatment. I am very 
positive in the opinion that neither ovarian nor uterine dis- 
ease can be cured as long as the rectum is in a diseased state ; 
certainly this rule will hold good save in the rarest of cases. 
For instance, we are told that a displaced uterus is one cause 
of haemorrhoids, and that we must remove the cause before 
we treat the effect. JNow this doctrine is so old and universal 
that we have learned to accept it as an axiom ; but, as there 
are exceptions to all rules, this must be classified as one of 
the exceptions. It has been my observation, first, that the 
majority of females, especially the married ones, have dis- 
placed wombs, if we are to go strictly by a mathematical or 
an anatomical line ; secondly, that of all affections (if dis- 
placement can be called an affection) that are difficult to rec- 
tify, the most difficult is displacement. The very method 
employed, namely, the use of a pessary, makes the case worse 
for the rectal surgeon than to leave the womb in the displaced 
position that it occupies. The walls of the rectum are more 
encroached upon by uterine supporters than by the displaced 
womb. If the patient be a male, a positive answer should be 
had, if possible, to the question whether he has ever had gon- 
orrhea or syphilis. His answer helps us very greatly to de- 
termine the reflex to the rectum, if disease per se can not be 
found there. For instance, all surgeons know that a stricture 



12 DISEASES OF THE RECTUM, ANUS. AND SIGMOID FLEXURE. 

of the urethra or an enlarged prostate will cause such reflex 
trouble to the rectum as to simulate rectal disease. Or, a syph- 
ilitic exudate infringing upon any nerve or nerve-center may 
cause the same. And yet, recognizing that patients often de- 
ceive us in this matter, in my clinics before my class, either 
at the college or hospital, I have ceased asking the patient 
any such question. I either make an examination of these 
parts myself or have my assistant do so. So often have I 
been deceived, and, after treating persons for rectal trouble 
simply upon symptoms, have found out that it was purely 
reflex, that I now search all organs possible in making up my 
diagnosis. And I also believe that syphilitic ulceration can 
be determined by the feel, without questioning the patient 
at all. 

Examination.— Any one who is in the habit of making rectal 
examinations will agree with me that the patient's word can 
not be taken ; and I also wish to say that you will often be led 
to a false opinion if you place too much credence in the notes 
that are sent you by the family physician. It has happened 
to me more than once, in examining a patient for so-called 



The Ncdofik sofa as a piece of furniture. 

haemorrhoids, to find cancer of the rectum. A short time ago 
a surgeon of some repute came to me a distance of three 
thousand miles, and, detailing his case, said that he was suf- 
fering from protruding piles. I asked him, after making the 
examination, if he had come to this conclusion himself, or 
had relied upon the opinion of others. He informed me that 
he had been examined by three other physicians. In reality 
this gentleman had a large protruding polypus and no piles, 



INTRODUCTORY. 



13 



at all. The slightest symptom around the anus or in the rec- 
tum is called piles. Upon the cover of every vaunted remedy 




Position ior rectal examination. 

for the cure of this disorder we read of itching piles. Of 
course this is a misnomer ; for piles, of themselves, do not 
itch. If this symptom be promi- 
nent, it can safely be said that 
the man has a pruritis, simple 
or complicated. Therefore we 
are to consider the proper meth- 
od of examining the patient, for 
it devolves upon you to make a 
correct diagnosis. The books all 
speak of the necessity of giving 
an enema before an examina- 
tion is made. This is true, ab- 
solutely true, in a great many 
cases, especially where you are 
in doubt ; but in the vast ma- 
jority of instances these people 
consult you at the office, have not the time or disposition to go 
to bed, or to follow out these instructions, and the great ma- 




Second position for rectal examination. 



14 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



jority of them can be diagnosticated without any such proced- 
ure. Such cases are those of external or internal haemorrhoids, 




Favorable position for operations upon the rectum. 

fissure, stricture, polypi, etc. And, therefore, I imagine that it 
is not of so great importance as it is said to be. If a further 

examination has to be made the pa- 
tient should not only be instructed 
to take an enema, but should also 
be given a purgative. A question 
of some moment is the character or 
style of the chair or table to be used 
for this examination. Above is given 
a cut which represents the best, in 
my opinion, for the purpose. I have 
never seen a chair that was in any 
way specially adapted to making 
examinations for diseases of the rec- 
tum. This sofa is so admirably suit- 
ed to the purpose that I give space 
enough here to insert four cuts, 
showing the different positions that 
patients can be placed in for rectal 
examination. This sofa is made by 
The Nedojik Manufacturing Com- 
pany, Wyeth City, Ala. 
If, for any reason, such a table can not be had, then I 




New illuminating lamp for throat, 
vagina, rectum, etc., made of 
metal, nickelplated. 



INTRODUCTORY. 



15 



would recommend that a plain, flat, wooden table be made, 
about three feet high, three feet wide, and five feet long, with 
two leaves attached at the foot by screws, that can be elevated 
or depressed. This makes a very simple and perfect examin- 
ing board, which can be manufactured for a very little sum. 
Some discussion has been given to the character of the light 
we should employ. I do not 
think there can be any doubt 
that, if a good natural light can 
be had, it is the best. If the 
room is so situated that this 
can not be obtained, then an 
artificial light can be employed. 
From the Argand burner, with 
the use of a head-mirror, we 
get a very effective light. The 
following represents what is 
commonly used by rectal sur- 
geons for this purpose. What 
is better, however, in my opin- 
ion, is the use of the small elec- 
tric light which has been de- 
signed specially for examining 
the throat and other cavities 
of the body. Here is the best 
battery, etc., that I have seen 
for the purpose of examining 
the rectum. It is made by Con- 
nable & Harper, Xenia, Ohio. 

This battery is very porta- 
ble, and consequently will be 
found of great service to the surgeon. It can be used within 
a moment's notice, and as a means of detecting ulcers, etc., in 
the rectum, especially those situated high up the gut, sur- 
passes any other method. Going with this battery is a cau- 
tery wire, which is easily controlled, and can be heated to any 
degree. It is far safer and better than the thermo-cautery. 




A parabolic metallic reflector, highly pol- 
ished, is secured to a spring candlestick 
in such manner as to collect the greater 
part of the light and throw it upon the 
parts to be examined. This light is near- 
ly sixteen times as great as that of a naked 
candle placed at the same distance. The 
candlestick can be taken apart, and then 
ccupies little space. It is cheap in first 
cost and in use. An adamantine candle 
— six to the pound — fits it and burns nine 
hours, at a cost of less than two and half 
cents. 



16 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



The next thing to be considered is the position of the 
patient. Some prefer the one nsed for lithotomy, the legs 
being held in position by Clover's crutch. For reasons that 




The Connable & Harper battery for office use. 

are self-evident, I believe that there are other positions better 
than this. I usually have the patient lie on the left side, 

with the legs and knees well drawn 
up, and the body in Sims's position. 
My friend Dr. R. O. Cowling, de- 
ceased, preferred the right side, and 
yet I believe that if both positions are 
practiced, the advantage will be found 
in having the patient lie on the left 
side. The pelvis should be slightly 
elevated, which throws the contents 
of the abdomen down toward the dia- 
phragm. I would suggest, for mod- 
esty's sake, that a sheet to cover the 
female patient should never be for- 
gotten. In examining this class of patients Dr. Horatio 




Flexible stem for electric li^ht. 



INTRODUCTORY. 



17 



Storer, of Boston, recommends eversion by the fingers passed 
into the vagina. I believe this to be of donbtful utility. It 
will be of no avail in the young and nnmarried, and even in 
those women who have borne children it is a very difficult 
thing to do. Of course, it is only the anterior wall of the 
rectum, and that very low down, that you will be enabled to 
see ; and granting that you 
could see it, it would amount 
to very little in a diagnostic 
way. The patient then being 
in the proper position, what 
are we to use in making an 
examination ? First of all, we 
are to detect an abnormal con- 
dition by ocular inspection. 
Such things as external piles, 
eczemas, external ulcerations, 
condylomata, fissures, exter- 
nal opening of fistulae, tracts 
of sinuses, marginal abscesses, 
can be seen without the use of 
any instruments. I wish to 
mention here that, whatever 
may be the condition found externally, the search should 
not be ended until a thorough examination has been made 
of the rectum proper. Granting that you might have 
one or all of the conditions that I have named, there 
might be more on the inside. I have known surgeons to 
form an opinion of fistulse in a patient by such inspection, 
operate for the same, and leave a close stricture above. If, 
then, you have come to a conclusion regarding the external 
parts, you are now to examine for any disease witliin the 
rectum. By far your greatest aid will be the finger. After 
many years' experience, I am satisfied that the majority of 
the diseases which affect the rectum can be made out by 
the educated finger. It is very seldom, in these plain cases, 
that I now use a speculum at all. By proper care, the in- 
2 




Examination of the rectum by electric 
light. (Connable & Harper.) 



18 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

troduction of the finger and the manipulation of the rectum 
with it cause very little if any pain, unless there be a seri- 
ous trouble existing. The finger should be thoroughly 
anointed with a tenacious grease ; none of the oils meet the 
indications so well as common lard or vaseline. Then, by 
practicing a boring motion, and directing the finger slightly 
forward, it will gradually and slowly relax the sphincters 
and pass into the rectum ; and here a definite idea can be 
had of the external sphincter muscle— whether or not an un- 
due spasm exists, or whether it be hypertrophied, or whether 
much pain is excited by the introduction. Having the finger 
well into the rectum, you are now to try to detect any abnor- 
mal condition. I wish to say emphatically that, if you have 
been led to believe that you can detect an ordinary case of 
internal haemorrhoids by means of the finger, you will cer- 
tainly be mistaken. Unless the tumors are enlarged and 
indurated by the inflammatory process, or have undergone 
atrophic change from age, they can not be detected by the 
finger in the rectum. The question now arises, What can we 
detect \ First of all, stricture of the gut. The pouch of the 
rectum is naturally large and capacious, and ordinarily the 
finger can be swept around it. But when the pathological 
changes have taken place which constitute a stricture, the 
finger at once detects it. Impacted fseces and foreign bodies 
can be detected ; a polypus hanging by its stem, or even with 
a close base, may be found by searching for it. It must be 
remembered, however, that the pedicle may be attached high 
up, and that the body of a polypus proper may be pushed 
above it, even into the sigmoid flexure. Therefore the pa- 
tient should be asked to " strain down," and the descent of 
the tumor may be noticed. Any ulcers of long standing, 
particularly those with a hardened base and indurated edges, 
can be easily detected. All malignant trouble can be made 
out, but I doubt the ability to detect, as is so often said we 
can, the opening of internal fistulse. One trouble is that 
they are sought for too high up. They are usually found in 
the depression between the external and internal sphincter 



INTRODUCTORY. 19 

muscles ; but, admitting their existence, it is a very difficult 
thing to tell it by any feel evidenced to the finger. While 
the finger is in the rectum of the male, I would advise that 
you feel for the prostate gland. It is said by many authori- 
ties that it is difficult to make it out when in its normal con- 
dition ; but from this I must dissent. It is the rarest excep- 
tion that the practiced finger can not only detect it, but also 
can make out its different lobes. If pressure upon it elicits 
pain, and you have failed to find any rectal trouble, you 
have sounded a key-note which will perhaps enable you to 
trace the symptoms to the proper part. The prostate has 
been frequently mistaken for a rectal tumor. Patients have 
been sent to me to have it removed, under the supposition 
that it was the beginning of some malignant trouble. A case 
is reported by some authority where the prostate was once 
ligated for an internal hemorrhoid. If the finger is in the 
rectum of the female, the position of the womb should be 
carefully noted. Upon divers occasions has this organ been 
mistaken for a tumor in the rectum. For the relief of such 
a tumor, of course, hysterectomy is the proper operation ; 
and if the organ is not diseased, we will let the gynaecologist 
take the blame. It has been questioned whether by the 
finger we can reach into the sigmoid flexure. I am satisfied 
that, if the patient be a short female, and is directed to 
''strain down," and the elbow of the surgeon is pushed by an 
attendant, the end of the finger can be passed into the flexure. 
The first instrument to be considered in making a rectal 
examination is the speculum. The great number got up 
for the purpose are very much like, in usefulness, the num- 
ber of pessaries that have been invented, equally of no ac- 
count. The chief fault has been that after they are intro- 
duced, we see more metal than we do bowel. Consequently, 
the majority of speculums that are used for this purpose are 
of little avail. To overcome the fault mentioned, I devised 
the one represented by the cut. It is easy of introduction, 
and reveals a great deal of the gut. A cut is also given 
of Dr. Kelsey's speculum, which he says is of great advan- 



20 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



tage in his hands. I have never had the pleasure of seeing 
the instrument. These are all bladed speculums and are 
used for detecting trouble within five inches of the exter- 




Speculum open at side. 




A fenestrated speculum. (Allingham.) 




Kelsey's rectal speculum. 



Cook's tubular speculum. 



nal sphincter muscle ; beyond that distance they will reveal 
but little. To meet this want, Dr. Cook has designed a 
tubular speculum, of different sizes, which is introduced 
upon a guide, and after its introduction the guide is re- 
moved. I have had much 
satisfaction from its use. 
For suspected trouble 
higher up than the blad- 
ed speculum will reach, I 
am in the habit of taking 
a long gutta-percha, tubu- 
lar speculum, and passing 
a No. 10 Wales rectal bougie through it as a guide, and, when 
w T ell into the rectum, withdrawing the bougie. Through this, 
as well as through the other speculum spoken of, the small 
electric light can be passed, and a nice observation be had of 
the gut proper. 




A fenestrated speculum. (Green.) 



INTRODUCTORY. 



21 




Tieman's rectal speculum 



It is best that the room should be darkened while using 
this light. By the use of speculum s, many diseases of the 
rectum can be diagnosticated, or the opinion made out by 
the use of the finger can be corroborated. Among the list I 
might mention ulceration of 



the bowel, malignant or syphi- 
litic disease, and especially 
would I call to mind that in 
many cases where vague symp- 
toms are manifest the epithe- 
lium may be peeled off, either 
for a considerable space or at 
a small point. I have detected 
such spots by a careful exami- 
nation with a long tubular 
speculum, and by the local 
application I have stopped 
the symptoms. Haemorrhoids, 
especially those well formed, 
can be seen with a valve speculum. A general proctitis can 
be seen by its use. Next in the list of instruments I should 

mention the probe, 
but I do not believe 
that it is of as great 
importance as some 
seem to think. We 
can see an external 
opening of a fistula, 
and we can feel its 
channel. If it is 
urged that we are to 
use a probe to de- 
tect any additional 
channels, I would 

Mathews's self-retaining rectal speculum. it , ,-1 _ 

r answer that the 

knowledge would aid us very little in the treatment of a dis- 
ease. It is the operation that cures, and whether there be 




22 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

one or half a dozen sinuses, they will all be attended to at 
the time of operating. If the sinus can be felt and no exter- 
nal opening detected, it is safe to conclude that the skin has 
closed over it. Then, by the aid of a probe, especially its 
sharp point, we can thrust it through the skin and open the 
channel, which is the proper thing to do in all such cases. 
For internal fistulse it is of greater utility ; for what appears 
not to be an internal opening is sometimes demonstrated by 
the probe to be one. Therefore, it is an aid in making such 
a diagnosis. The next instrument I wish to mention only 
to condemn. With all deference to such authorities as Al- 
lingham, Kelsey, Ball, and others, who place great stress 
upon their use, I must differ from them in a positive manner. 
I allude to the use of rectal bougies. Formerly, the old Eng- 
lish bougie, made of a very hard material, was the only one 
used. I am certain that it has done much mischief. I re- 
member once in my own practice, after having operated upon 
a man for a cancerous stricture, and wishing to keep this 
dilated as well as possible, I introduced one of these rectal 
bougies. Within a few hours the man complained of intense 
pain ; rapid peritonitis set in, and the patient died. I am 
satisfied that the bougie entered the peritoneal cavity. The 
consolation that I had was that the upper rectum was em- 
braced by the cancer, and that accounted for his death. Lat- 
terly, I have used the Wales rectal bougie, which is made of 




Wales's rectal "bougie. 

soft rubber, having a hole through its interior. If any are to 
be used, these are decidedly the best. They are said to be 
of service in detecting a stricture located above the reach of 
the finger. First, I will say that I would doubt a diagnosis 
made out by such means, unless I had a more positive evi- 
dence. It is a very difficult thing to pass these instruments 
without detecting an obstruction ; and if we use indiscrimi- 



INTRODUCTORY. 23 

nately the bougies for such detection, we would have a 
wonderful number of strictures to contend with. Fortu- 
nately, the bougie is made so that a stream of water can 
be passed through it. By this means it sometimes will 
follow its own course ; but when we consider, first, that 
few are experts in its use, and, second, that it is a dan- 
gerous instrument, remembering that the upper part of the 
rectum is movable gut, the dangers that are incident to its 
use outweigh by far any good that can come by detecting a 
stricture in that locality. 

The Eectal Sound. — A number of the authors recommend, 
and a number of them have devised, a rectal sound, for the 
purpose of detecting stricture beyond the reach of the finger. 
I would urge the same objection to their use as to the rectal 
bougie, with the addition that they are more dangerous, in 
that they are made usually of a hard material. It would take 
the services of an adept to insert one of these into the sig- 
moid flexure, even if a stricture did not exist ; and if one 
did exist, it would be a very difficult thing to tell it. Then, 
again, presuming that we suspect a diseased condition, it can 
be readily understood that the point of this rectal sound, 
which is usually cone-shaped, could be thrust into the peri- 
toneal cavity. 

The Hand.— In 1872 Prof. Simon, of Heidelberg, published 
an article entitled The Artificial Dilatation of the Anus and 
Rectum, for Exploration and Operation, in which he first de- 
scribed a method of exploring the lower bowel by the intro- 
duction of the entire hand. By this method of examination 
he asserted that he was not only able to explore all the pelvic 
organs and to distinguish all pathological changes that might 
have taken place, but that the greater part of the abdominal 
cavity could also be reached. He further asserted that this 
method was so entirely free from danger that he had not 
hesitated to practice it on patients anesthetized for other 
purposes. He limited the depth to which the hand should 
penetrate to the upper part of the rectum and the lower part 
of the sigmoid flexure, and claimed only to palpate the ab- 



24 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

domen somewhat above the umbilicus. Since that time some 
have asserted that the hand could be made to enter the de- 
scending colon. Dandridge, in an article on the manual ex- 
ploration of the rectum, in the Reference Hand-book of the 
Medical Sciences, says, in answer to this assertion, that it can 
be shown on the cadaver to be a physical impossibility. 
Many others who have written on the subject modify the con- 
clusions reached by Simon. Many accidents have followed 
an attempted introduction of the hand into the rectum, and 
no one who is acquainted with the anatomy of the parts will 
deny that, in disease especially, it is a dangerous procedure, 
and that the operation should be limited to very exceptional 
cases. Even if a penetration of the cavity does not take 
place, in many instances incontinence of faeces would result. 
However, this is the least of all the accidents, the main one 
being the rupture of the peritoneal coat. And yet, with all 
these dangers threatening us, I believe that the procedure is 
warranted in some cases. 

A Case. — I was called a short while ago, in consultation with 
Drs. Roberts and Grant, of this city, to see a man who was 
suffering from total obstruction of the bowel. From the his- 
tory of the case they had ruled out acute obstruction, but 
they were unable to locate the point of obstruction. Inci- 
dentally I would remark that it is a very difficult thing to 
define or circumscribe a tumor in the sigmoid flexure, espe- 
cially if the abdomen is large or contains much fat. I know 
that many claim to do this, but I believe that it is in the 
rarest of cases that it can be accomplished. Many times I 
have tried to find malignant trouble of the sigmoid flexure 
by palpation, but I do not remember but one case where I was 
successful in so doing, although the after-history proved that 
it existed. Too much stress, in my opinion, is placed upon 
this method of examination, and we should seek for further 
and better means. I have said that, granting that there was 
malignant trouble in the upper rectum or in the sigmoid, it 
is a dangerous manoeuvre to introduce a bougie or sound 
into it. Therefore we are forced to think of other measures. 



INTRODUCTORY. 25 

In many cases the cancer is confined to the sigmoid, and the 
rectum proper is not affected. This patient referred to was a 
man abont forty-five years of age and in a robust condition. 
His weight would have exceeded two hundred pounds ; con- 
sequently, the abdomen, being tympanitic, was enormously 
distended. The attending surgeons had failed to locate the 
point of obstruction, although it was total. I suggested the 
administration of chloroform, and that I be permitted to in- 
troduce my hand for the purpose of making a diagnosis. 
This was agreed to. The hand being well anointed with 
vaseline, two fingers were first introduced through the sphinc- 
ter, then four, and finally the thumb and whole hand. This 
was done by a rotatory motion. I felt the sphincter muscle 
plainly give way. Pushing up my two fingers to the entrance 
of the sigmoid, I detected a well-formed cancerous growth, 
into which I could scarcely insert one of my fingers, but all of 
them could sweep around the tnmor. It could be plainly seen 
that the correct diagnosis was a malignant tumor of the sig- 
moid flexure. I advised an immediate laparotomy, which was 
done. I claim that in this class of cases where, by the ordinary 
means, a correct diagnosis can not be arrived at, we are justi 
fied in introducing the hand for this purpose, but it should be 
remembered that the size of the hand must be considered 
Simon says that a hand measuring twenty -five centimetres 
(nearly ten inches) in circumference may be introduced abso- 
lutely without harm. Of course, he means in a normal condi- 
tion of the gut. My hand measures eight and a fourth inches 
in its widest circumference, and I have had no difficulty in 
introducing it into the rectum upon several occasions. A 
number of years ago I reported to the Kentucky State Medi- 
cal Society a case where I introduced my hand and arm into 
the rectum, and broke down a stricture at the entrance of the 
sigmoid flexure. Dr. O. E. Herrick, of Grand Rapids, Mich., 
says, in an article on rectal explorations, published in Leon- 
ard's Illustrated Medical Journal, of October, 1880, that he 
has had occasion to test repeatedly the method which, as he 
says, consists of passing the hand up the rectum along the 



26 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

curvature of the sacrum and up through the pelvis, where the 
hand could pass in any direction, and all the organs, not only 
in the pelvis, but also in the abdominal cavity, can be got 
at by this method. He reports a number of cases, and says 
that the discovery has proved a valuable one to him, and thus 
far there have been no unpleasant results following the opera- 
tion. This does not coincide with the statement of Dan- 
dridge, but I am much inclined to believe with Dandridge in 
his limits of the method, and that beyond said limits it is a 
physical impossibility to do what is claimed. I can not dis- 
miss the subject without saying again that it is a dangerous 
procedure, and should be resorted to only in exceptional 
cases. I am never in the habit of giving the patient an anaes- 
thetic for a physical exploration of the rectum, but when it 
comes to the introduction of the hand it is of the greatest ne- 
cessity, and it could not be done without the use of ether or 
chloroform. 

Rectal Examination in Relation to Life Insurance. — There is one 
class of patients especially that indicates to us the necessity 
of a rectal examination, not so much for their benefit as for 
that of the life insurance company about to assume the risk. 
The importance of a thorough examination of all applicants 
for life insurance is well known and can not be overesti- 
mated. So well recognized is this, that all life companies aim 
to secure the services of competent physicians as examiners. 
Yet none know so well as themselves that many are received 
who should not be. Whether this is due to incompetency on 
the part of the examiner or to gross neglect, we will not stop 
to argue ; but, be this as it may, it is certain that injustice is 
done the membership or company each time that ai] appli- 
cant is passed by the examiner who is below the physical 
standard. So careful is the State of its citizens' welfare, that 
1 aws looking to their protection are enacted, and each com- 
pany seeking to do business in any State must conform to 
these laws, or be prohibited from doing business within its 
borders. In keeping with this, each reputable company seeks 
to protect those already insured from any imposition ; hence a 



INTRODUCTORY. 27 

long list of questions, looking to the confirmation of good 
health and a sound family history, is asked, and the applicant 
is required to undergo a rigid physical examination. If he 
stands the test, he is accepted ; if he does not, he is rejected. 
The reason for rejection is sometimes based upon that which 
the longevity of the applicant afterward proves to have been 
a mistake ; as, for instance, the height of the individual must 
be in proportion to a certain measurement of the chest and 
abdomen or to the weight of the body. Again, if an appli- 
cant shows a family history of tubercular trouble, he is liable 
to be rejected ; or, if he has already a lung deposit, he is cer- 
tain not to be recommended, notwithstanding the fact that 
many persons whose parents, one or both, have died with 
phthisis, have themselves escaped the disease altogether, and it 
is a well-known fact also that phthisical patients have been 
cured. I do not cite these instances to condemn the action of 
the companies, but it must be conceded that the applicant 
must be protected in his rights equally with the company. If 
he be rejected, either through the incompetency of his medi- 
cal examiner or through the fault of the company's rulings, 
he is forever barred from acceptance in other companies. The 
responsibility of the medical examiner for life insurance is a 
very grave one, and, I am inclined to believe, often over- 
looked. The comfort, happiness, and even the lives of many 
may rest upon his decision. Each and all of us are more or 
less interested in this subject, and the belief that the rectal 
surgeon can settle some points that are generally overlooked 
by a life company and its examiners forms my excuse for 
mentioning this subject here. I have myself been the exam- 
ining surgeon for a number of life companies, and it was im- 
pressed upon me at the time that sufficient investigation was 
not given to the rectum in forming an estimate of the longev- 
ity of the applicant. In relation to this subject I desire to 
make four propositions : 1. That there are diseases affecting 
this portion of the body which are wholly unrecognizable save 
by a careful exploration of the rectum. 2. That when syphi- 
lis, cancer, or tuberculosis attacks the rectum, they are gen- 



28 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

erally attended with fatal results. 3. The interim between 
their incipiency and development is so vaguely marked that 
nothing less than a full exploration will reveal their nature. 
4. That if, during this interim, the person were to apply for 
life insurance, he would be accepted, other things being equal. 

That trouble which is often fatal is manifest first in 
the rectum can not be denied. Under this head can be 
placed cancer and tubercular disease, and I have frequently 
called attention to the fact that syphilis may develop in the 
rectum when it has not been recognized in a secondary way 
in any other portion of the body. To elucidate my meaning 
contained in the four propositions named, I have taken at 
random a few cases from my record-book : 

Case I. — Mr. C, about forty-five years old, came to me, at 
the suggestion of his physician, for an examination of his 
rectum. He remarked that his doctor was not sure that he 
had rectal disease, nor was he ; yet, because of the fact that 
he strained at stool and passed a little blood and mucus, he 
thought it best to be examined. Placing him in Sims's posi- 
tion on a hard table and in a good light, I carefully searched 
the rectum with a speculum, but could find no disease. Re- 
moving the instrument, I inserted my finger, and asked the 
patient to strain down, when I was enabled to explore the 
gut for five or six inches. At the end of my finger I detected 
an indurated spot, which seemed to extend upward. Rea- 
soning by exclusion, I could not imagine any other disease 
w^hich could cause this hard, nodular, little tumor, located 
at this spot. Although there was no gland involvement, I 
was firmly of the opinion that this man had incipient cancer. 
He was given treatment by injections, etc., and in a few days 
the symptoms cleared up and there was no discharge of 
either blood or mucus, and no straining at stool. After 
this he took a long journey of about fifteen hundred miles, 
and upon his return he called at my office to say that he had 
entirely recovered. He had a rest from all bad symptoms for 
a month or six weeks. During this interim he applied for a 
life policy of ten thousand dollars, passed the examination 



INTRODUCTORY. 29 

(no attention being paid to his rectum), and was insured. 
After a while his condition grew worse ; a discharge of blood 
and mucus was noticed ; he began to emaciate ; took on a 
bad color ; and in less than six months perforation took 
place, and he died — of cancer. 

Case II. — Mollie T., unmarried, about, twenty-eight years 
of age, of easy virtue, gave a history of primary syphilis, 
though no evidence of a secondary manifestation of the dis- 
ease. Having money, she was not subjected to the expos- 
ures, etc., that are incident to such a life. She came to me 
to be treated for constipation. Upon examining her, I de- 
tected, about three inches above the external muscle, a close 
stricture. I advised her to have it divided. She said she 
would consent to any treatment but this ; consequently grad- 
ual dilatation was practiced, until a No. 8 Wales bougie 
could be passed through it. After this she failed to report 
to me for a number of months. When I saw her again, the 
stricture was as close as when I first examined her. I should 
mention that after the two dilatations a large mass of fsecal 
accumulation passed away, aided by the syringe. After the 
second course of treatment she again disappeared, and I did 
not see her for months, after which she dropped into my office 
one day to say that she was not doing well, and thought she 
would have the stricture divided. I warned her, as I had 
often done before, that, if she did not attend to it, she might 
die in consequence of the neglect. Although she said she 
believed this, she did not report, but I learned a few days 
after seeing her that she had started on a long journey. A 
telegram was received on the morning of the third day after 
her departure, saying that she had died suddenly. Her 
physician wrote me that her death was evidently caused by 
a perforation into the peritoneal cavity ; and, she having time 
to tell him of her stricture, he added in his note that the 
perforation was likely caused by fecal impaction above the 
stricture, or an extension of her disease — in which opinion I 
fully concur. 

Case III. — A gentleman, aged thirty, consulted me foi 



30 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

constipation. His history was much like that of many who 
suffer from this trouble. He said he had taken purgatives, 
in all forms and doses, until they had lost their effect. A 
close examination of his rectum developed the fact that a 
stricture existed at the entrance of the sigmoid flexure. He 
was put under chloroform and the stricture dilated by the 
aid of the hand pushed into the rectum. He has since died 
of his trouble. If this man had applied for life insurance 
in any company, even up to the very date that he first saw 
me, giving the same symptoms as were given me, viz., only 
those of constipation, he would have been accepted, and yet 
his death was caused from a condition that could be detected 
only by a rigid search into the rectum as high as the sigmoid 
flexure. 

Case IV. — Dr. B. asked me to see with him a young 
married woman w T ho was strangely affected. He said that 
she had been constipated for a long time, but was now un- 
able to pass an action at all. An examination of the rectum 
revealed a stricture about an inch and a half above the ex- 
ternal sphincter muscle, which would not admit of the pas- 
sage of a lead-pencil. This woman, to all appearances, was 
in perfect health, about twenty-two years of age, weighing 
one hundred and forty pounds, of medium height, of florid 
complexion, good appetite, and cheerful spirits. Certainly, 
she w^ould have been admitted into any life company that re- 
ceived women. The doctor gave her an anaesthetic and I did 
a free proctotomy upon her. Since then I have divided this 
strictured condition twice, at intervals of one and two years. 
The trouble, however, will likely be the cause of her death. 

Case V. — A young man, aged twenty-five, was brought 
to me by Dr. G., complaining of a frequent disposition to go 
to stool, and at such times passing only mucus and blood. 
With the finger I easily detected a hard, nodular infiltration 
into the gut, which extended up it for four or five inches, 
too high to be excised. My diagnosis was cancer. Under 
the injection plan, his symptoms grew better, the discharge 
ceasing for a time. For months thereafter he appeared in 



INTRODUCTORY. 31 

good health, not losing a pound of flesh, and eating and 
sleeping well. After a while his symptoms reappeared, the 
deposit in the mucous and submucous tissues gradually ex- 
tended, strictures formed, glandular involvement took place, 
there were loss of flesh, bad color, etc., and the man eventu- 
ally died of cancer. 

Case VI. — A lady, married, mother of six children, aunt 
of the last patient, came to my office to consult me for piles 
and some constipation. Apparently, she was in good health. 
She said she had been advised a good while before to con- 
sult me, but was prejudiced against me for the reason that I 
had treated her nephew so long without benefit. An exam- 
ination of her case showed the existence of two strictures 
of small caliber, located two and three inches, respectively, 
above the sphincter muscle. It was a singular coincidence 
that an aunt should object to me because I did not cure her 
nephew of cancer, and that, in making my examination of 
her, when she complained only of piles, I should find that 
she also had cancer. I stated to her that her condition 
was more serious than she apprehended, and to her husband 
I explained her condition. I did a proctotomy on her, open- 
ing up the strictures thoroughly, gave good drainage to the 
wound, and for a while she did well, but eventually went 
from bad to worse, and died. 

Case VII.— Mrs. P., the wife of a doctor, accompanied 
by her brother-in-law, who was also a doctor, came to me to 
be examined for some trivial rectal trouble. I found a scir- 
rhus cancer blocking the entire rectum. She died in about 
eight months. 

These cases will suffice to illustrate my points. 

Summary. — The first case verifies all four of the proposi- 
tions laid down. First, the disease could not have been rec- 
ognized except by a thorough exploration of the rectum. 
Second, it proved to be both serious and fatal. Third, in the 
interim between its incipience and full development, the pa- 
tient applied for and secured a life policy, and the company 
suffered a loss of ten thousand dollars. This man suffered 



32 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

sufficient symptoms at least to have called for some examina- 
tion of his rectum, and this is the point that I wish specially 
to make, that the examiner for life insurance should question 
the patient thoroughly as to any rectal manifestation of dis- 
ease, and that the patient's diagnosis of piles, etc., should not 
be taken ; but, if any obscure symptoms exist by reflex or in 
other ways, the rectum should be examined. 

Case II substantiates the proposition as well, except that 
no application for life insurance was made. It might be said 
that in this case a history of syphilis was given, and for this 
reason the person would have been rejected. In answer, I 
would say that in many cases of syphilis the only local mani- 
festations are found in the rectum ; therefore they might 
escape the detection of the examiner, and a false opinion be 
formed. Then, too, the fact that a person has once had a lo- 
cal sore is not prima facie evidence of syphilis, Again, it is 
not necessary that stricture of the rectum should result from 
either cancer or syphilis, as is evidenced in two of the other 
cases where the cause was benign. Cases V and VI demon- 
strate that malignant trouble may exist in the rectum and 
give but little intimation of its existence. During the time 
of its latency, if the person so affected should apply for life 
insurance, the chances are that he would be accepted. In 
each and every instance, I believe that a careful rectal ex- 
ploration would reveal the true nature of the disease, and its 
detection would save the company the amount of the policy. 
Whereas, no life company, to my knowledge, requires a rectal 
exploration of the applicant, still it expects of its medi- 
cal examiner to trace out all forms of disease which would 
prevent the taking of the risk. I do not wish to be under- 
stood as saying that all applicants for life insurance should 
have a rectal examination before they are passed, but I do 
say that these three forms of fatal diseases — cancer, syphilis, 
and tuberculosis — when appearing in the rectum, are so 
masked in their symptoms that nothing less than a physical 
exploration of the rectum will reveal the nature of the dis- 
ease. 



CHAPTER II. 

ANATOMY OF THE RECTUM. 

It is a very essential thing, in examining and manipulating 
the rectum, and in doing surgical operations upon this part, 
to know its anatomy. Hence I have taken occasion to say 
that it is a, bad practice for teachers to advise the free use of 
long instruments in making examinations of the gut. When 
we remember that a large portion of the rectum is not at- 
tached, but is a movable, floating membrane, we can easily 
understand how such an instrument could be pushed into the 
peritoneal cavity, with but little force, especially when the 
parts are in a diseased condition. Again, as has been inti- 
mated, death may follow the introduction of the hand into 
the rectum, and a forcible divulsion of a stricture, under cer- 
tain conditions, may be fatal. The rectum, then, should be 
studied both in its anatomical and pathological aspects. 
We have spoken of the intimate relationship that the rec- 
tum bears to the other organs, by contiguity and continuity^ 
It is important to know these relations in order to under- 
stand and to trace the many reflex symptoms that are met 
with in the diseased or altered conditions. 

The rectum begins at the sigmoid flexure and ends at the 
anus. Its length has been variously estimated. Some say 
that it measures from six to eight inches when in position, 
there being a gain of an inch or two when it is dissected out 
and laid flat. Bodenhamer claims that he has frequently 
seen specimens which measured eleven inches. I think that 
the height of the individual usually controls the length of the 
part. A person measuring six feet will have a longer rectum 
than one measuring Ave and one half feet. This, at least, is 



34 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

the best guide in forming an opinion as to how far an instru- 
ment must be inserted before it reaches the sigmoid flexure. 
I am satisfied that in some short women the rectum is not 
longer than five inches. 

For convenience of description, and to get a good anatomi- 
cal bearing, it is best to divide the rectum into three parts : 
the first part, four inches ; second part, three inches ; third 
part, one and one half inches. For the location of disease 
and anatomical bearings this is best. For the dangers to be 
apprehended from manipulation it is best to say that one half 
of the rectum is in a fixed condition, and the other half is 
floating, or not fixed. Now, this arrangement seems to have 
been fixed by Nature according to the true principles of me- 
chanics, viz., " A pipe upon the end of a flexible hose facilitates 
the discharge." It should also be remembered that the serous 
coat of the rectum is from the peritonaeum and invests the 
first part entirely, and that the meso-rectum dips in front of 
the second part. Therefore the rectum is not a straight tube, 
but has its boundaries and curves, surrounded by danger-sig- 
nals, all of which should be remembered in passing instru- 
ments, either for the purpose of making a diagnosis or of 
operating upon the parts. 

Shape and Relations. — The rectum is club-shaped, narrow 
above, with a pouch below. Immediately above the sphincter 
muscles the dilatation is noticed. I would call attention to 
the fact that there is a great difference in this pouch in cer- 
tain individuals, which does not accord with accepted teach- 
ings. O'Beirne taught that in a normal condition, when the 
pouch was empty, the folds were in apposition, the same as 
in the pharynx, when not distended by a bolus of food. 
Others give certain measurements which are said to be accu- 
rate. As a rule, I believe that in the majority of cases 
O'Beirne's idea is correct, but it is to any definite or positive 
rule that I wish to object. There is a certain condition 
sometimes observed in these examinations that is supposed to 
be caused by disease, which I am sure is often only natural, 
and has no significance in determining disease, I allude to 



ANATOMY OF THE RECTUM. 35 

the large, capacious, and empty pouch of the rectum. It 
feels as if the finger had entered a great cavity, and some- 
times it is difficult to touch the sides. I have known medical 
men to be confused upon meeting with such cases, and very 
many good surgeons say that it affords an evidence, nearly 
pathognomonic, that a stricture or obstruction exists above. 
I must confess that at one time I held to this view, but by a 
careful watching of these patients it was observed that it was 
not true — the condition was a natural, not an abnormal one. 
I do not wish to convey the idea that no stress is to be put 
upon this state of the rectum when disease actually exists 
above ; for I hold this one symptom of the greatest value in 
making out a stricture at the entrance of the sigmoid flexure, 
or an obstruction in it, but, to be satisfied of it, I would want 
more clinical facts than the simple existence of this very free 
dilatation of the pouch. 

Relations. — First part : Behind, with the pyriformis muscle, 
sacral plexus, branches of the internal iliac, which separate 
it from the same ; iliac symphysis. Second part : Behind, 
close to the concavity of the sacrum. Third part : The anal 
muscles. 

First part : In front, the convolutions of the intestines 
separate it from the bladder in males and the uterus in fe- 
males. Second part : In front, with the triangular portion 
of the base of the bladder ; vesiculse seminales ; more ante- 
riorly with the prostate in males, and in the female it adheres 
to the vagina. Third part : In front, in the male it is sepa- 
rated by the perinseum from the membranous portion and the 
bulb of the urethra. 

Surgical Importance.— 1. Communion with vesical, uterine, 
urethral, and vaginal troubles. Not only are rectal disturb- 
ances frequently the result of each and any of these, but, vice 
versa, all contiguous organs suffer whenever the rectum is dis- 
eased. 2. The dilatability of the female rectum. If for any 
reason it is thought best to introduce the hand into the rec- 
tum, it is fortunate for both the patient and the surgeon if 
the subject be a female. 3. These truths remembered, dilata- 



36 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

tion or division of stricture can be accomplished when located 
in the fixed portion, but any attempt to do so with the upper 
portion is extremely hazardous. 4. It can be seen that opera- 
tions upon the bladder can be done through the trigone vest- : 
cale, as the second part only is covered above by the peri- 
tonaeum. The space extends three or four inches above the 
anus. It has been a subject for discussion, viz., what is the 
average distance from the anus to the point where the serous 
coat leaves the wail of the rectum % Quain says four inches ; 
Allingham, from two to five ; and Cripps, after much experi- 
menting, concludes that the average measurement is two and 
one half inches when the bladder and rectum are both empty, 
and an additional inch when distended. It is of the greatest 
importance to settle definitely, if we can, this question, as the 
safety of the patient's life may depend upon it ; yet I must 
confess that it is a difficult thing to do. A thorough study of 
the individual case would go further in determining this point 
than any general rule. 

Muscular Coat. — The muscular coat resembles the balance of 
the intestinal tract in having an external longitudinal and an 
internal circular layer. There is some difference, however, in 
the further arrangement of the fibers. The bands disappear 
at the sigmoid flexure and the longitudinal fibers take their 
place. Dr. Garson, in a paper read before the Boston Medi- 
cal Association, names the fibers at the point of contact of 
the rectum, bladder, and prostate rectovesical fibers. It is 
not an inappropriate name, as these fibers form a firm band 
of union between the organs. The muscular fibers of this 
coat, in my opinion, play a decided part in constipation. If, 
for instance, pressure for any length of time is kept up 
upon them, they lose their elasticity and are unable to per- 
form their function. 

Submucous Coat.— This coat furnishes a bed for blood-ves- 
sels. It is thicker and more dilatable here than elsewhere, 
and because of its general make-up allows the mucous mem- 
brane to move freely upon it. 

Mucous Membrane.— The mucous membrane of the rectum is 



ANATOMY OF THE RECTUM. 37 

thicker and of a darker color than that of the rest of the gut. 
I have often been impressed with the observations of physi- 
cians who come to see this special work. "The gut is won- 
derfully congested," they often say, when, in fact, it was pre- 
senting a natural appearance. It is of the utmost importance 
for the student who expects to give any attention to diseases 
of the rectum to familiarize himself with the physical ap- 
pearance of the parts. This coat is more vascular and more 
movable than that in any other part of the tract. Hence it 
is that when the sphincters contract it is thrown into longi- 
tudinal folds. These folds are often the means of arresting 
the bougie as it is pushed into the rectum. These, however, 
are effaceable. and the rectum can be seen even to its inter- 
stices with a good dilating speculum. Besides these, Mr. 
Houston described some ineffaceable folds, which have re- 
ceived the name of Houston's semilunar valves. That the 
student may have an opportunity of looking for them I will 
give the location where it is said they can be found : 1. Near 
the commencement of the rectum, on the right side. 2. On 
the left side, opposite the middle of the sacrum. 3„ On the 
fore part of the rectum, opposite the base of the bladder. 
Here they are said to be the best defined and more constant. 
4. One inch above the anus, on the back part of the rectum ; 
but they are said to be not constant. 

Their Use. — To support the faecal mass. 

I have been thus explicit, for the reason that I deny their 
existence, and if they did exist I would deny that their use 
was "to support the faecal mass." 

For many years I have searched for these folds and I have 
yet to encounter them. In my opinion, they existed only in 
the author's "mind's eye." 

Pockets and Papillae. — After the lapse of many years another 
great anatomical discovery (?) has been made, and it is left 
for the traveling peddler or itinerant to herald it, not to the 
profession but to the world at large. We are informed that 
we are liable at any time to be attacked by " pockets and pa- 
pillae," and that these "lesions" are fearful to behold. We 



38 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

are told that " they are as common as piles and more prolific of 
mischief than yon could possibly imagine " ; that " these con- 
ditions are the most mischievous of all rectal affections," and 
it is advised that they be immediately cut ont. Instruments 
of all kinds and many devices have been invented, by which 
a free excision of these terrible " pockets" can be made, and 
they are advertised for sale "at a very low price," so that 
they are really within the reach of everyone, be he surgeon or 
not. Consequently, at many of the cross-roads yon will find 
men ready to relieve you of the dangerous and fearful malady. 
Now the truth is, these so-called " pockets and papillae" are 
normal structures and are not pathological at all. I can not 
state the facts more tersely than has Dr. Edmund Andrews, 
the distinguished surgeon of Chicago, who says : " The sac- 
culi Horneri are not lesions and usually do no harm ; on the 
contrary they, in conjunction with adjacent grooves and con- 
cavities, hold the reserve of mncus required to lubricate the 
anus." 

In evidence of the correctness of this position he publishes 
a letter from Prof. Henry N. Smith, a distinguished anato- 
mist. Dr. Smith says : " The rectal pouches (sacculi Hor- 

,* 

neri) are normal structures, intended to hold mucus which 
is forced out in defecation, to lubricate the margin of the 
anns and protect it from hardened faeces." 

Below are given the views of Prof. C. W. Kelly, Pro- 
fessor of Anatomy in the Kentucky School of Medicine, 
Louisville, Ky. 

Louisville, Ky. 

Prof. J. M. Mathews. 

Dear Sir : The pockets found in the rectum just above 
the internal sphincter mnscle assist in the act of defecation by 
receiving and retaining mucus, which keeps moist the faBcal 
mass, and lubricates the parts which facilitate the evacuation 
of the discharge. 

The sacs aid the dilatation of the lower part of the rectnm 
during the peristaltic expulsive efforts of the sigmoid flex- 
ure and colon. The papillae found at intervals between the 



ANATOMY OF THE KECTUM. 39 

pouches are constant, and both of these structures are found 
in health, and are consequently normal and natural to the 
parts. Very truly, C. W. Kelly. 

Prof. J. M. Bodine, Professor of Anatomy in the Medical 
Department of the University of Louisville, and Prof. Dugan, 
Professor of Anatomy in the Hospital College of Medicine, 
both regard the "pockets," "papillse," and "pouches" as 
normal structures. 

For a number of years I have been trying, in my lectures 
to students and in the medical periodicals, to refute this false 
anatomical doctrine, and it affords me pleasure to subjoin 
such testimony as that of these distinguished authorities. 
!No one knows so well of the great damage that is being done 
by these ignorant itinerants in cutting away the normal struct- 
ures of the rectum as the surgeons who see the results of this 
foolish practice. Haemorrhage, ulceration, fissures, strictures, 
and inflammation of the rectum frequently follow in the 
wake, and it may be that the surgeon profits in pocket, but 
the patient suffers in health. I have now under treatment a 
most excellent woman from the central part of the State, who 
submitted to the "treatment." She is really in a deplorable 
condition in consequence, and it will take a long time to re- 
duce the extensive proctitis from which she is now suffering. 

External Sphincter Muscle. — This muscle is one of the most 
important in the whole body, for the reason that it opens 
and closes the anus ; and, if by disease or trauma its office 
is destroyed, the person is rendered miserable for life. In- 
continence of fseces results, and no greater calamity could 
befall the sensitive person. 

Although a little out of place in this chapter, I feel like 
taking the opportunity of warning those doing rectal surgery 
against injury to this muscle. In women, especially, who re- 
quire surgical treatment of the anus or rectum, be careful, 
very careful in your divulsions and cuttings of the muscle. 
In patients, either male or female, who are disposed to a 
weakened condition of the muscle, you must tax your sur- 



40 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

gical ingenuity to prevent any harm being done to it. This 
muscle is more developed and better defined than the internal 
sphincter. It has both voluntary and involuntary power. It 
is made up of a flat plane of fibers, and is closely adherent 
to the integument. It is elliptical in shape, and completely 
surrounds the anus. It is likely to become greatly hyper- 
trophied by the inflammatory process, and, from the fact 
that it controls, more or less, the peristaltic action of the 
bowel, it is a great factor in producing constipation. The 
nerve-supply is from the hemorrhoidal branch of the inter- 
nal pudic and the hemorrhoidal branch of the fourth sacral. 
It arises from the tip of the coccyx and is inserted into the 
perineal center. In making a cut for fissure or stricture, if 
the median line is closely hugged, the muscle will not be 
divided. 

Internal Sphincter. — This muscle is difficult to define. It is 
situated immediately above the external sphincter, but is 
only two lines in thickness. It has not nearly the surgical 
importance of its neighbor. As an anatomical guide, in lo- 
cating the openings of internal fistulse, it subserves a good 
purpose, for they are usually between the two. 

Is there a third sphincter muscle 1 Kelsey, in his work 
on Diseases of the Rectum and Anus, in discussing this sub- 
ject, says : "From a study of the literature of this question, 
and from the results of dissections and experiments which 
we have personally been able to make, we are led to the fol- 
lowing conclusions : 1. What has been so often and so differ- 
ently described as a third or superior sphincter-ani muscle 
is, in reality, nothing more than a band of the areolar mus- 
cular fibers of the rectum. 2. This band is not constant in 
its situation or size, and may be found anywhere over an 
area of three inches in the upper part of the rectum. 3. The 
folds of mucous membrane (Houston's valves), which have 
been associated with these bands of muscular tissue, stand in 
no necessary relation to them, being also inconstant and vary- 
ing much in size and position in different persons. 4. There 
is nothing in the physiology of the act of defecation, as at 



ANATOMY OF THE RECTUM. 4^ 

present understood, or in the fact of a certain amount of con- 
tinence of faeces after extirpation of the anus, which necessi- 
tates the idea of the existence of a superior sphincter. 5. 
When a fold of mucous membrane is found which contains 
muscular tissue, and is firm enough to act as a barrier to the 
descent of the fseces, the arrangement may fairly be consid- 
ered an abnormity, and is very apt to produce the usual 
signs of stricture." 

The only exception that I would make to any of these 
conclusions is to No. 2, which says, u This band is not con- 
stant in its situation or size." I would beg to amend by say- 
ing that the band in many instances is entirely absent. I 
quite agree with all these conclusions of Kelsey, and would 
relegate the third or superior sphincter-am muscle to the 
company of "Houston's valves" and of the "pockets and 
papillae." 

Levator Ani. — This is a very important muscle, from a sur- 
gical standpoint. It takes its origin in front from the pos- 
terior surface of the body and ramus of the pubes, on the 
outer side of the symphysis ; posteriorly, from the inner sur- 
face of the spine of the ischium ; between these points from 
an angle of division between the obdurator and the recto- 
vesical layers of the pelvic fascia on their under surface. The 
general origin is from the under side of the true pelvis. Its 
insertion posteriorly is to the tip and sides of the coccyx. 
More anteriorly, they unite with each other to form the pos- 
terior rliaplie. In the middle : The largest portion is inserted 
into the sides of the rectum, blending with the fibers of the 
sphincter muscle. Anterior : The largest fibers descend on 
the sides of the prostate gland and unite with the fibers from 
the opposite side, blending with the fibers of the external 
sphincter and transversus perinei at the tendinous center. 
Inferiorly it is related by its convex surface to the sacro- 
sciatic ligaments and the gluteus maximus. Posteriorly it is 
in contact with the lower border of the pyriformis. Its action 
is to draw the coccyx up, or, when both muscles act together, 
to fix that bone and prevent its being pushed backward in 



42 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

defecation. Its fibers unite with those of the opposite side 
beneath the neck of the bladder, the prostate, and the ure- 
thra. This muscle acts as a support to the pelvic organs. It 
prevents the rectum from being protruded. It also acts upon 
the neck of the bladder, because it incloses it, and in the act 
of defecation the bladder is pressed upon and the urethra 
closed. It is easy to be seen, then, that any abnormal condi- 
tion of this muscle would reflect upon the bladder and the 
prostate, especially, and that many affections of them can 
be traced to this spasmodic action of the muscle, which is 
caused, of course, by some diseased condition. It can be 
also understood that these organs, being diseased, will reflect 
to these muscles, causing much of the distress which has 
been described in a preceding chapter. The muscle receives 
its nerve-supply from the fourth sacral and internal pudic. 

Recto-Coccygeus. — This muscle is located directly under the 
levator ani, as it goes to make up the floor of the pelvis, be- 
tween the tip of the coccyx and the anus. Its office is to 
hold the end of the rectum to a given point in defecation. 
If it is injured, either by disease or by trauma, it is with the 
greatest difficulty that the act of defecation is accomplished. 

Transversa Perinei. — The main function of this muscle is to 
aid the act of defecation. The two muscles are sometimes 
continuous and form a half ring, and brace the anterior part 
of the rectum. 

Blood-supply of the Rectum. — The rectum receives blood from 
three different sources. The upper part is supplied only by 
the superior hemorrhoidal, a branch from the inferior mes- 
enteric, which also supplies the lower part of the colon. 
The terminal branches of the superior hemorrhoidal pass 
to the lower part of the rectum, but the principal blood- 
supply to this part comes from the middle and inferior 
hemorrhoidal, which are primary and secondary branches 
from the internal iliac, which artery affords the principal 
blood- supply to all the pelvic viscera. The middle hemor- 
rhoidal is distributed to the pouch of the rectum, while 
the inferior, a branch from the internal pudic, passes across 



ANATOMY OF THE RECTUM. 43 

the ischio-rectal fossa and reaches the rectum at its lower 
part. The internal pudic, besides giving a large supply 
of blood to the rectum, supplies blood to the bladder, pros- 
tate, vagina, perinseum, and external organs of generation. 
The veins which return the blood from the rectum are numer- 
ous. The hemorrhoidal plexus communicates in front with 
the vesico-prostatic in the male, and the vaginal plexus in the 
female. While the inferior -and middle hsemorrhoidal arte- 
ries supply the principal part of the blood to the lower part 
of the rectum, the corresponding veins return but a small 
portion of this blood ; almost all the blood from the rectum 
passes through the superior hemorrhoidal veins and into the 
portal system. 

In the chapter upon the anatomy of the rectum in relation 
to the reflexes, we have given the nerve-supply of these 
parts. 



CHAPTER III. 

CONSTIPATION. 

Perhaps there is no subject of as much importance to the 
rectal surgeon as that of constipation. Patients suffering 
from this trouble drift to him after having gone the rounds 
with the general practitioner. It is a well -recognized fact 
that patients are allowed to make their own diagnosis in 
this affection, and that the physician drops into error by 
prescribing accordingly. We must also recognize that con- 
stipation is a relative term. Whatever we may teach and 
believe in regard to its effects, the history of patients will 
frequently unsettle any such doctrine. To properly under- 
stand the subject, it is necessary to consider both the anato- 
my and the physiology of defecation. O'Beirne, of Dublin, 
believed that the rectum in its natural state was very like 
the oesophagus when it was not distended with food — in 
other words, that its walls were in apposition. He claimed 
that the rectum, in its normal state, would show the folds 
lying closely together, and that they were only distended, 
or effaced, during the time that the pouch was filled with 
faecal matter. According to his views, when a peristal- 
tic action of the bowel proper occurred, the faeces would pass 
from the caecum, through the colon, and thence fall into the 
rectum. If this call of Nature is heeded, a natural evac- 
uation takes place ; if it is not, an anti-peristaltic motion 
occurs, which lifts the mass back into the sigmoid flexure. 
Now, we must remember that the evacuation is composed 
partly of solid material but mostly of water. If the dis- 
charge is according to health rules, it passes as Nature in- 
tends ; but if there is a refusal of the same on the part of the 



CONSTIPATION. 45 

person, or from some physiological reason, then the water is 
reabsorbed and passes into the circulation, while the solid 
material is lifted back and remains in the sigmoid flexure. 
Therefore, in considering the accumulations in which the 
fa?cal mass plays part, we are to look to two points specially, 
namely, the ccecum and sigmoid flexure. The ascending, 
descending, and transverse colon are free from such obstruc- 
tion. The muscular coat of the rectum is composed of cir- 
cular and longitudinal fibers. The circular are internal, the 
longitudinal are external. It is an aggregation of the circu- 
lar fibers which go to make up the sphincter muscles, and 
also that which stands guard between the sigmoid flexure 
and the rectum. These fibers are separated from the mucous 
membrane by loose areolar tissue. The longitudinal fibers 
pass down the external aspect of the rectum to its lower bor 
der, and thence curve under the internal sphincter muscle. 
They then ascend and are attached to the substance of the 
areolar tissue. This will explain the eversion of mucous mem- 
brane which takes place in the act of defecation. The longi- 
tudinal fibers draw down the sphincter in this act, and the 
levator muscles retract it. It has been stated before, in the 
anatomy of the rectum proper, that the mucous membrane is 
movable. It can be now understood how it is that eversion 
of the mucous membrane takes place during the act of defe- 
cation. It being a truth that the membrane is everted during 
this act, it can be seen that any rough substance — as a matter 
of fact, if printed paper be used as a detergent — it could 
produce such a condition of the blood-vessels as would 
ultimately terminate in haemorrhoids, etc. It becomes the 
province of the surgeon who gives attention to these diseases 
to lay down rules of health to his patients in regard to this 
very common subject of constipation. It can be very well 
understood how non-attention to the calls of Nature would 
produce faecal accumulation in the rectum, or sigmoid flex- 
ure, or possibly the caecum. It is very natural to infer that 
the anti-peristaltic motion of the bowel could lift, for a cer- 
tain time, the mass, or portion of the mass, from the rectum 



46 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and would land it back into the flexure ; but if constipation 
becomes a disease, or the bowels are not unloaded for a num- 
ber of days, yet this effort would be made by Nature, a por- 
tion of the mass would be left in the rectum, even grant- 
ing that a portion of it was lifted up and landed back 
whence it came. Therefore, the watery element being ab- 
sorbed, and constipation progressing, we are likely to have an 
accumulation, as has been intimated, first in the sigmoid flex- 
ure, next in the rectum, and, lastly, in the caecum. Now, it 
is a well-known fact that such accumulation has ended in 
the death of the patient. Obstruction, caused by faecal mat- 
ter in the caecum, has been confounded, time and again, with 
appendicitis, and operations have been done looking to the 
removal of the appendix, which were unwarrantable ; and 
right here begins the discussion of that much-discussed sub- 
ject, whether these cases belong to the surgeon or physician. 
If the accumulation of faecal matter be in the caecum, it is 
evidently a case for the physician. If, as the abdominal 
surgeon says to-day, these cases are, nearly without excep- 
tion, an inflammatory condition of the appendix vermiform- 
is, then such cases belong to the surgeon, and an operation 
for the removal of the appendix is justifiable. We believe 
that accumulations of faeces do take place, in the locality and 
order named. I must differ from some surgeons who believe 
that the favorite site of obstruction by faecal accumulation 
is the rectum proper. Therefore, I shall take occasion, in 
writing the chapter on impacted faeces, to state that, in my 
opinion, the most important part to be looked after is the 
sigmoid flexure, and not the rectum, for such trouble. I also 
quite agree that the caecum may be so loaded as to be ob- 
structed, and that the symptoms are both confusing and mis- 
leading ; and, recognizing the physiology of defecation to be 
as we have given it, we believe that a fair trial with medi- 
cine, to the border-line at least, should be given before sur- 
gery is thought of. Now, while I agree with O'Beirne in the 
main, I must disagree with him, in an every- day observation 
of the normal bowel, as to the condition of the same. In the 



CONSTIPATION. 47 

majority of instances, I believe that there is some accumula- 
tion in the rectum, of faeces, after the daily evacuation has 
taken place. Therefore I am to conclude, if he is correct 
about the anti-peristaltic motion of the bowel, that there is 
also an accumulation in the sigmoid flexure. In other words, 
I believe that if the rectum is examined, some hours after 
the natural evacuation of the day has taken place, faeces may 
be found within its folds. This, at least, has been my ob- 
servation. That they are of a dry character, devoid of the 
watery constituents, which have been absorbed, is the truth, 
and I am very much inclined to his view that, if the daily 
evacuation is not observed, the main portion of the mass 
is lifted back into the sigmoid flexure. This I believe to be 
one of the chief reasons for the disorders and disease found 
in the flexure, of which but little account is given in the 
books. Now, if we are to take for granted the statements of 
O'Beirne, which are corroborated by many who have written 
upon the subject, we can understand how these accumula- 
tions in the rectum and the sigmoid flexure would derange 
the whole pelvic circulation. Outside of doing damage to 
the mucous membrane of the parts, causing congestion, in- 
flammation, and ulceration of the same, such accumulation 
is liable to produce external piles, to make internal growths 
bleed, and to cause a general atony of the gut, by pressure 
upon its muscular coat and an interference with its fibers. 
It is very natural, then, to suppose that a person in this con- 
dition should suffer from a so-called constipation, and seek 
the advice of a physician. It is needless to say that the pre- 
scription usually given is a purgative. It also goes without 
saying that such a prescription never relieves the patient. 
Indeed, if we would stop for a moment to consider the effect 
of a purge under such circumstances, we would be deterred 
from giving it. When we remember that the veins of the 
rectum have no valves, that the erect position of the human 
being, etc., renders these parts liable to a congested state of 
the vessels, it is no wonder that many diseases incident to 
the rectum follow in consequence of a neglected condition 



48 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

which terminates in constipation. The natural pressure ex- 
erted by the mass in the sigmoid flexure or the rectum pre- 
vents the return of the venous blood, and hence causes a vari- 
cose condition of the veins. This, if kept up, ends in haem- 
orrhoids. The passage of such a mass is the most frequent 
cause of fissure of the anus. Internal fistula may result from 
direct pressure, causing inflammation, and then ulceration or 
abscess, and then fistula. By the temporary paralysis of the 
bowel, caused by the accumulated mass, its tonicity is lost, 
and hence prolapsus may result. If impacted faeces remain 
as the result of constipation for any length of time, this self- 
constituted irritant may not only result in ulceration of the 
bowel, but, in its effort to cicatrize, a stricture may be estab- 
lished. So it can be seen that many diseases of the rectum 
are caused by constipation and its results. But these local 
diseases are not all. The natural refusal to abide by the 
calls of Nature ends in constipation, and from this state many 
diseases result. It is a well- recognized fact, as intimated, 
that the faeces are at first soft, made so by the water that 
they contain. It is also true that, if the calls of Nature are 
not heeded, the watery constituent is absorbed, and, being 
absorbed, passes into the blood. 

It is very easy to understand what the effect of all this is. 
Faecal matter can be no more nor less to the natural blood 
than a poison. The red corpuscles are diseased by it ; they 
are altered in color and have less power ; their health-pro- 
ducing and life-giving property is destroyed. Instead of 
the red cheeks and bright complexion, the rapid circulation 
and energy that are supplied and caused by these corpuscles, 
we have, after the absorption of the faecal mass into the cir- 
culation, the sallow complexion, dark rings under the eyes, 
cold extremities, a less supply of oxygen, and a lethargy 
which is due to a vitiated condition of the blood and en- 
feebled corpuscles. The system is not nourished as it was 
intended that it should be, and in consequence there is a loss 
of flesh. The diseased blood resulting from this condition 
now circulates to the nervous system, hence we have nervous 



CONSTIPATION. 49 

depression. If we examine a patient under these circum- 
stances, we will find that the pulse is slow and easily com- 
pressed, and the organs of digestion and assimilation are 
very much interfered with. These patients will tell you that 
they suffer from a loss of memory, and especially that they 
are unable to concentrate their thoughts on any single sub- 
ject for any length of time, and that in their daily voca- 
tions they are overcome by drowsiness, which interferes with 
their business as well as their happiness. Although they 
are frequently drowsy and go to sleep even when trying to 
pursue their business vocations, they are not relieved by 
sleep, either by day or by night. If this condition con- 
tinues, all the functions of the body may be deranged, and, 
if not relieved, actual disease and suffering are the result. 
There are many factors concerned in the production of con- 
stipation which vary in different cases : First, it must be 
agreed that where food is not properly digested or assimi- 
lated, the intestinal tract must suffer, and eventually end 
either in a diarrhoea or constipation. Second, it is too much 
the habit, in treating a functional stomach indigestion, to 
forget that an intestinal indigestion may also exist. Third, 
there may be deficiency of fluid in the intestinal canal, caused 
by want of a proper supply of food, excessive waste, or 
deficient secretion from the intestinal mucous membrane. 
Fourth, there may be a deficient peristalsis, especially in the 
large intestine, from defects of diet or from atony due to 
over- stimulation by purgatives, or to degeneration of the 
muscular coat from the effects of pressure by the faecal mass, 
as the result of the accumulation of the faeces. Fifth, inhibi- 
tory influences of the nerve-centers of the brain and cord, 
probably affecting both peristalsis and secretion of fluid. 
Sixth, deficient bodily exercise and movement. Seventh, 
dilatation of the intestines, especially the colon, due to de- 
bility of the intestinal wall, or to actual dilatation by accu- 
mulated faeces, gaseous distention, repeated enemata, or lax- 
ness of the abdominal wall, etc. Such are the chief causes, 
ordinarily considered, which give rise to constipation. Any- 



50 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

thing that weakens the muscular fiber of the intestine, such 
as deterioration by age, mental depression, deficient bodily 
exercise, astringent food, direct pressure, etc., is. a well-recog- 
nized cause. In children, putting aside malformation, such 
as atresia, more or less complete, peritonitis, intussusception, 
etc., as causes, we have : First, food which leaves little resi- 
due—very completely digestible food, e. g., milk — faecal mat- 
ter too small to duly excite peristalsis. Second, deficiency 
of liquid food, not enough to drink, causing dry faeces. 
Third, deficient biliary secretion. Fourth, deficient secretion 
of glands of the mucous tract, and dry faeces. Fifth, over- 
stimulation, and consequent atony of the intestines ; loss "of 
excitability and loss of power, caused (a) by coarse food ; (b) 
by frequent purgatives ; and (c) by too frequent use of ene- 
mata. To these may be added, both in the adult and in chil- 
dren, the dread of evacuation because of pain excited by 
hard stools. The resistance to the passage of faeces, partly 
voluntary and partly reflex, is caused by the pain that is 
brought on by the act, from the sensitive condition of the 
anus, especially by the existence of a fissure. The symptoms 
produced by the retention of faecal waste in the intestines are 
very remarkable. In some cases there may be absolutely no 
derangement of the general health. This holds good, whether 
the patient be a child or an adult. They may eat and sleep 
well, be hearty and robust, and look the picture of health. 
Although the physiology of defecation tells us that the ab- 
sorption of this watery constituent of the faecal mass continu- 
ally takes place and is a poison to the blood, in many of 
these patients there appears to be no faecal absorption of the 
foul matter from the intestines. Indeed, the chief difficulty 
is the pain caused by the passage of the hardened, dry fae- 
ces. If it be a child, it screams and cries, and dreads the ac- 
tion, and will not assist by its own efforts. If an adult, they 
will tell you that the torture is so great when the bowels 
move that they will not permit an evacuation to take place, 
and yet often you will find that the tongue is clean and nu- 
trition good. When we consider the anatomy of the rectum, 



CONSTIPATION. 51 

we see that it is ill constructed for the purpose of a reservoir 
for the feces. It differs very materially from the portions 
of the large intestines above it. As we have said, there are 
two strong layers of muscular fibers, the longitudinal and 
circular. The three longitudinal bands of fibers from the 
colon pass down over the rectum, two over the anterior and 
the other over the posterior surface. In addition to these, 
we find fibers to the rectum, placed in the intervals around 
the walls between these bands, forming altogether a uniform, 
strong, muscular layer. The internal or circular muscular 
coat is composed of strong fibers, placed close together and 
much stronger than any other part of the intestines. The 
sudden thickening and strengthening of this coat at the 
upper end of the rectum was first called attention to by 
O'Beirne, and has received the name, and is still designated 
by some authors as, "a sphincter of OBeirne" In speaking 
of the anatomy of the rectum, I have said that I did not be- 
lieve or concur in the opinion that such aggregation of fibres 
existed at this portion of the gut as could be properly called 
a sphincter, and I am sure that, in those instances where such 
a condition is detected, it can not account for the holding 
of the fsecal mass in the sigmoid flexure, or preventing its 
passage down into the rectum. The internal sphincter mus- 
cle is found at the lower border of the circular coat, where it 
forms a band or ring, made up of an aggregation of fibers. 

We find near the center of the rectum two collections of 
circular fibers ; one encircles the anterior, the other the pos- 
terior, wall of the rectum. The anterior is about three inches 
from the anus, and corresponds to the bottom of Douglas's 
cul-de-sac. The posterior is about an inch higher, and above 
the rectal pouch. These bands have been called the third 
sphincter muscle. Although their existence has been dem- 
onstrated, especially by Dr. Chadwick, of Boston, I can not 
believe that they act as a sphincter. Nor can I believe 
they are sufficient to make the prominent projections on 
the inside of the gut which they are described as making. 
Dr. Chadwick says: "At about two and a half inches from 



52 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

the anus the finger encounters a confused mass of folds, 
through which the canal can be discovered only by consid- 
erable burrowing. Here an annular constriction, diminishing 
the lumen by about one half, seems to be felt. If, now, the 
rectum be distended with water, the finger will almost inva- 
riably detect, in place of lax folds, what still seems to be an 
annular constriction, but which a more careful exploration 
will show to be composed of two distinct semicircular bands, 
slightly overlapping each other, the posterior being some- 
what higher than the anterior." 

My observation, after a diligent investigation of the sub- 
ject, has led me to believe that the conclusions of Dr. Chad- 
wick and others are, to a degree at least, erroneous. That the 
passage of a rectal bougie is frequently obstructed by the nat- 
ural folds of the rectum is a fact ; that in some instances there 
is an aggregation of fibers at the upper portion of the rectum, 
giving evidence to the finger of what might be taken for a de- 
cided constriction, may be true ; and, more than this, I can un- 
derstand that such a case as Syme reports could occur. He 
says : " Three hundred hours were spent by a reputable phy- 
sician and surgeon in introducing a bougie, at regular inter- 
vals, to dilate a stricture high up in the rectum. After the 
death of the patient from other causes, the post-mortem ex- 
amination showed that no stricture had ever existed, but that 
the end of the instrument had lodged in this fold against the 
sacrum." Any surgeon who is in the habit of introducing in- 
struments into the rectum recognizes the fact that the end of 
an instrument is frequently caught and entangled in the nat- 
ural folds of the gut. But that the constrictions exist which 
form, or may be mistaken for, a third sphincter, I have never 
yet seen, and outside of the declaration, anatomically, I do 
not believe that there is any physiological demonstration of 
its existence. Nor do I believe that the internal sphincter 
muscle has much to do with the physiological act of defeca- 
tion. But I do believe that the external sphincter muscle 
has not received that amount of consideration in this act that 
it deserves. My attention to this muscle as a factor in con- 



CONSTIPATION. 53 

stipation was first called by the lamented Dr. Richard O. 
Cowling, who said to me as long as fifteen years ago, while 
engaged in a conversation with him on this special subject, 
that he believed that, in many cases of chronic constipation, 
it could be overcome, or benefited at least, by the free 
divulsion of the external sphincter muscle. Upon his sug- 
gestion, I tried this in a few cases that would permit it, and 
reported the result to one of the medical societies. I remem- 
ber that the benefit was very decided in the majority, if not 
all, of the cases. In the operations for internal haemorrhoids 
ever since, I have been in the habit of divulsing the muscle, 
mainly to prevent pain after the operation, which is caused 
by its contraction. Many cases which had suffered from 
constipation before have been relieved, and I have attrib- 
uted this relief more to the divulsion of the muscle than 
to the removal of the haemorrhoids. The lower end of the 
rectum is closed by this external sphincter muscle. This is 
the true sphincter, composed of voluntary muscular fibers, 
placed close beneath the delicate integument surrounding 
the anus and removed from its neighbor the internal sphinc- 
ter, by about a line. It is placed here as a guard for 
the natural evacuation of the faeces. The nerve-supply of 
this muscle is greater than that of any other muscle in the 
body, consequently, it is easily irritated, and irritates in re- 
turn. The nerves come from three different sources, the in- 
ternal pudic, the fourth sacral, and the posterior sacral, and, 
if we trace out the nervous distribution, we would find that 
it is in close sympathy with all the contiguous parts ; but, 
as we have given this nerve- supply under the head of "Re- 
flexes," it is unnecessary to mention it here. 

The desire for an evacuation of the bowels begins when 
the faecal mass first presses against the rectal mucous mem- 
brane. This is due to the impression produced on the termi- 
nal branches of the spinal nerves distributed to the rectal 
walls. This is the first point in the intestinal canal where 
we are aware of the movement of the intestinal contents. As 
the rectal contents pass on through the pouch, the internal 



54 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

sphincter, like all the involuntary fibers, relaxes to allow the 
mass to pass. When the mass falls into the rectum, there is 
an automatic contraction of the external sphincter muscle. 
This contraction increases as the mass advances, and it is 
greatest when the mass presses against the branches of the 
internal pudic nerve, at the upper border of the internal 
sphincter muscle. The contraction now of the lower part of 
the rectum, assisted by the pressure of the abdominal con- 
tents, produces a final discharge of the mass, but before it is 
ended, the levator ani contracts and elevates the perinseum. 
This elevation of the perinaeum seems necessary to discharge 
the last part of the faeces. As the longitudinal fibers con- 
tract, they tend to shorten and strengthen the rectal walls, 
and, as some say, to draw the gut up over the faecal mass. 
Those inserted beneath the mucous membrane evert the 
membrane slightly. This everted portion is retracted at the 
close of the act of defecation. My investigations of the ac- 
tion of the internal and third sphincter muscles do not coin- 
cide with Dr. Chadwick's. He says: " The finger in the 
anus would invariably give rise within a few seconds to those 
peculiar sensations which we all recognize as indicative of an 
impending evacuation of the intestines, even though the ex- 
creta may not have descended so far as to press on the peri- 
naeum. In every instance these sensations would be speedily 
followed by the emergence from the still lax folds at the 
point of constriction of a mass of more or less solid faeces, 
which would descend rapidly to the anus. If, at this mo- 
ment, the finger is kept applied to the distended semicircular 
bands, their muscular fibers could be plainly felt to contract 
behind the faecal mass until the lumen of the rectum was 
completely occluded. Further careful observation with the 
finger led to my detecting a distinct relaxation of the tonic 
contraction of these bundles of circular fibers just before the 
faecal mass had reached that part of the rectum. In other 
words, a distinct inhibitory action came into play. My at- 
tention was next directed to the action of the internal sphinc- 
ter. In this thick bundle of the circular fibers of the rectum 



CONSTIPATION. 55 

my finger speedily detected a relaxation in front of the 
descending faeces." 

I have already stated that I did not believe that the so- 
called third sphincter, or the internal sphincter, played a 
great part in the physiology of defecation. I think that the 
" peculiar sensations which we all recognize as indicative of 
an impending evacuation of the intestine," which can be 
caused by the introduction of the finger or any other irritant, 
such as, for instance, a glycerin suppository, are due to the 
effect of nerve irritation upon the muscular fibers of the gut 
proper, not to the so-called action of the internal and third 
sphincter ani muscles. Granting that the aggregation of cir- 
cular fibers is sufficient to constitute a third sphincter mus- 
cle, and admitting the office of the internal sphincter to be 
such as is claimed by Dr. Chadwick, it would appear 
that, in some cases at least, after the external sphincter 
was destroyed, we» would have these muscles assuming a 
double duty, as one organ often does for another, and that 
they would be able to retain and control the faeces ; but 
we know as a fact, and teach it as a truth, that, if the 
external sphincter muscle is destroyed by any operations 
around the rectum, incontinence is bound to follow. The 
simple declaration of this fact shows beyond dispute 
that all the allowance for the control of the faecal mass is 
vested in this muscle ; and, therefore, in speaking of consti- 
pation, I have thought fit to pay more attention to it as a 
factor in producing and keeping up this condition than is 
usually given to it. When the faecal mass, propelled by the 
involuntary action of the intestines, reaches the lower end of 
the rectum at unseasonable times, the external sphincter is 
firmly contracted by voluntary effort to resist the powerful 
expulsive efforts of the rectum. T^his is the only muscle at 
the lower end of the rectum which has such power. It is 
purely a voluntary muscle, and contracts by reflex action in 
response to any local excitation. When an irritability of 
this muscle is kept up, it will naturally increase in size and 
strength ; and it is not only the voluntary action of the mus- 



56 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

cle that is increased in force, but the constant presence of 
feces in the rectum, and their pressure on the terminal 
branches of the internal pudic nerve at the upper border of 
the internal sphincter, produces an increased irritability of 
the muscle, and this contraction will increase with irritation, 
until the muscle will cease to respond perfectly to the will, 
when it desires to relax it, and what was a voluntary obstruc- 
tion becomes an obstruction beyond the power of the will to 
entirely remove. 

It is asserted that the internal sphincter muscle also be- 
comes somewhat changed in its action, but I believe that such 
change can not be compared with the changes that take place 
in the external sphincter. I have no doubt but that the mus- 
cle relaxes as the faeces descend, and to that extent does not 
offer any obstruction to the act of defecation, but I have never 
seen the internal sphincter muscle become hypertrophied by 
excessive use, or a reflex irritability. Th# whole rectal wall 
contracts during the act, which forces the faeces out. Of 
course, this is aided by the abdominal muscles and diaphragm. 
When there is atony of the muscular coat of the rectum, this 
contraction does not take place, and consequently it is with 
great difficulty that the rectum is unloaded. The external 
sphincter muscle, therefore, is easily irritated, and conse- 
quently when the surrounding organs are diseased, being in- 
timately connected with this muscle through the nervous 
system, a rigid contraction often takes place, and this is a 
serious obstacle to the free passage of the faeces. Now, if 
the irritability of the muscle is kept up, it becomes en- 
larged, and a constant contraction exists which causes the 
faecal mass to be held in the pouch of the rectum, and as a 
result we have atony of its coats. As has been demonstrated 
in this connection, both the rectum and sigmoid flexure are 
filled with faeces. The colon may be doing its duty, but every 
portion below is refusing. When the abdominal muscles 
exert their force, it happens that a descent of the faecal mass 
only takes place to the sigmoid flexure and rectum ; but this 
very force, which in the normal state aids the dilatation of 



CONSTIPATION. 57 

the sphincter and the expulsion of the faecal mass, is now the 
cause of its being held within the rectum. Whenever the 
mass encroaches upon the fibers of the external sphincter, 
this contraction takes place at once, and the muscle closes in- 
stead of dilating, which is reversing the order of things. It 
must be understood also that if the constipation has become 
chronic, the watery portion of the mass has been rapidly ab- 
sorbed, and we find the remaining faeces in a dry and hardened 
condition. If this lies in the pouch of the rectum for any 
length of time, not only does it excite a congestion, but a sub- 
sequent ulceration of the coats ; and granting that the faeces 
are removed, and perhaps daily evacuations made to take 
place, the ulceration will keep up this reflex of the muscle, 
and cause it to act in the same manner that the pressure upon 
the nerves did when the pouch was impacted. These being 
facts, it is clearly demonstrable that the external sphincter 
muscle is a great if not the greatest factor in producing con- 
stipation. When we remember that it does not take much to 
irritate or excite this muscle, because of its extensive nerve- 
supply, we can set down in the list such things as fissures, 
irritable ulcers, abrasions, small openings of internal fistulae, or 
marginal openings of an external fistula, pruritus, etc. ; indeed, 
any condition that would excite nerve irritation will cause 
this muscle to contract in the manner named, and the result 
will be the establishing and keeping up of the constipated 
habit. I have no doubt but that the effect of a purgative 
given under these conditions will tend to keep up the constipa- 
tion instead of curing it ; in other words, it excites the same 
character of irritability of the muscle, and tends to produce 
its rigid contraction, and yet the majority of physicians pre- 
scribe purgatives, and the layman is so well educated to the 
fact, that he buys and keeps in his house some character of 
purgative, which he not only takes himself, but gives regu- 
larly to his family. There are a number of firms in the United 
States which have made immense fortunes by throwing upon 
the market different character of purgatives. Many of these 
preparations may be very admirable, and it is not to the pur- 



58 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

gative itself that I object, but it is to the impression given 
the people that they are to use them upon all occasions. I 
have said in this chapter that constipation is a relative term. 
I mean more especially, in the application of this word, that 
it should refer to the effect that constipation has in a general 
way upon the person that is the subject of it. 

In 1889 I reported to the Southern Surgical and Gynaeco- 
logical Association, held at Nashville, Tenn., what I was 
pleased to call a "Unique Case of Constipation." It was as 
follows : 

In the month of July of that year I was asked to see a pa- 
tient in consultation with Drs. Blackburn and Corrigan. The 
patient was a young lady eighteen years of age, style bru- 
nette, weight one hundred and fifteen pounds, height about 
five feet seven inches. Coming into the room in a graceful 
and easy manner, she sat down and gave this history of her- 
self in a concise and intelligent way : " Eight years ago I first 
noticed that I was taking on a costive habit. I would go for 
a number of days without having an action from my bowels. 
It was not until I noticed that a movement was not had for 
several weeks at a time, and then with great pain, that I called 
my parents' attention to my condition. They gave me pur- 
gatives ; sometimes they would act, often they would not. 
Of course, stronger medication was resorted to, and accom- 
plished so little good that at last my parents became alarmed 
and called in a physician. He treated me for constipation in 
the usual way, but I derived no good from it. Physician 
after physician saw me, each one treating the case very much 
alike. From two weeks the time extended to one month 
between my actions, until now the usual time, and I might 
say regular time — for it is with great regularity that they 
act — is four months. At one time I went for nearly seven 
months without a movement. At present it has been three 
months since I had an action, and I do not feel any dispo- 
sition to do so. I should also mention that for several years 
I have had much trouble in voiding the urine ; so much, in- 
deed, that I was advised by my physician to buy and use a 



CONSTIPATION. 59 

catheter. I use it many times during the day and night. In 
that respect I can not get along without it. About two years 
ago, just after I had passed the instrument into the bladder, 
I suffered great pain. Withdrawing it, I had an irresistible 
desire to strain, and in the effort passed a good-sized stone. 
The attending physician took it to a chemist, and I under- 
stand that he says that it does not look like a stone that came 
from the bladder, but I know that it came from mine. My 
appetite is only fair, I am seldom hungry, and yet I eat quite 
enough, I suppose. I sleep badly, but that I attribute to my 
nervous condition." 

After this recitation by the patient we turned our attention 
to the parents, who corroborated in every particular what the 
girl had said. Recognizing that often very great deception is 
practiced by patients, we questioned these honest folk in pri- 
vate, and they assured us that they had often put a watch on 
the girl to substantiate or disprove her statements, and each 
time it proved the truth of what she said. This was easily 
done, as she often did not leave her room during the four 
months, and some one was always with her. Her father re- 
marked that a movement from his daughter' s bowels was not 
only an event in the family but to the entire neighborhood. 
This was due to the fact that an action caused so much pain 
that she could be heard screaming all over the square. She 
would then have a swooning spell which would last for several 
hours, and they would often think that she would die. A 
careful examination of the patient was made upon the second 
visit, when I was accompanied by Drs. Blackburn and Yance. 
The following was what we observed, and the result : 

Tongue slightly coated, complexion muddy, pulse sixty, 
temperature normal, no enlargement of abdomen, tympanitic, 
or otherwise. No indurations or tumors, menses regular and 
normal in quantity. The patient was put under the effect of 
chloroform by Dr. Cary Blackburn, and I asked Dr. Yance 
first to explore the bladder, the symptoms indicating that it 
should be done. This he did, and at first thought that he 
detected an encysted stone. He quickly changed his mind, 



60 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

however, and pronounced the bladder free from stone and in 
a normal state, except that it was unusually large. Placing 
the patient in Sims' s position I explored the rectum. Divuls- 
ing the sphincter muscles freely, I first introduced a large- 
sized speculum, oval-shaped, but could not find any unnatural 
condition. I then passed my hand into the rectum and felt 
into the sigmoid flexure with my finger. No obstruction, 
contraction, or impaction existed. There was present in the 
flexure some soft faecal matter. Removing my hand I then 
introduced a No. 12 rectal Wales bougie, and through it 
flooded the colon with hot water. The anaesthetic was stopped, 
when we noticed that the pulse was very weak, and for fifteen 
minutes we thought she would die. Hypodermics of ether 
and whisky, together with inhalations of nitrite of amyl, 
brought her around. The bad symptoms of shock were dis- 
appearing, when she went into a cataleptic state, which lasted 
about thirty minutes. In a few days she was back to her 
usual condition. What we did in this case never seemed to 
affect her for good or evil. I believe the history given by the 
girl to be truthful in every particular. There could have been 
no reason for deception. She was as desirous of being cured 
as any patient could be. The points that I would especially 
call attention to are : 

1. The length of the time between the actions from the 
bowels, averaging four months. 

2. The fact that no impaction, disease, or unnatural con- 
tracted condition, existed in the bowels. 

3. That no odor emanated from the body. 

4. That little damage was done to the general health. 
Treatment.— Having, I think, fairly demonstrated that the 

sphincter muscle is the principal factor in at least keeping up 
chronic constipation, I submit that the first thing to be done 
in such a case would be to examine this muscle, and if found 
to be in an irritable state freely divulse it. Now, I know that 
the majority of patients would hesitate to take an anaesthetic 
to have this done, and it can not often be accomplished 
without it ; and I also know that many physicians would 



CONSTIPATION. 61 

advise their patients against this procedure ; but when we 
consider that constipation breeds a thousand ills that flesh is 
heir to, and also recognizing the fact that it is a disease, and 
one that is most difficult to cure, I feel that we are fully 
justified in advising the operation. Therefore, having selected 
the case that is suitable, under the instructions and precau- 
tions that have been given, especially where all medication 
has failed, I would have an anaesthetic administered, and 
divulse the sphincter in the following manner : It must be 
understood that a partial effect of the anaesthetic will not do, 
but that it requires complete anaesthesia in order to divulse 
the muscle without pain. When the patient is pronounced 
ready, I take either the Cook or Mathews speculum, anoint- 
ing it well with vaseline, pushing it into the rectum, and then 
divulse as widely as the blades will distend the muscle. Then 
withdrawing the speculum, I anoint my two thumbs, and slip- 
ping them into the rectum, I hook them snugly over the 
sphincter muscle, and distend gently but forcibly ; then insert- 
ing the three front fingers of each hand into the rectum, and 
removing the thumbs, I practice a kneading, or massage, of 
the muscle. Here I want to say that I do not follow the au- 
thorities who advise the breaking of the sphincter muscle in 
our efforts at divulsion. Even in the operation for irritable 
ulcer or fissure, I am not in the habit of doing this. Some 
harm might result from its breaking, but no harm can result 
or ever has resulted in my practice from this manner of divul- 
sion. I frequently say to my class that the guide which shows 
me that the divulsion is complete is the descent of the folds 
of the rectum, even with the external sphincter, which is pro- 
duced by the straining of the patient, or the natural falling 
down of the folds. After the divulsion has been accomplished, 
I either give a hypodermic injection of one fourth of a grain 
of morphine, or I insert into the rectum a suppository contain- 
ing one grain of solid opium, and one half-grain of the extract 
of belladonna. The parts should be sponged with very hot 
water every hour or two until the soreness disappears. On 
the third morning the patient is able to get up. My habit is 



62 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

to follow this operation by injections of cool water given daily, 
flushing not only the rectum but sigmoid flexure with it. I 
have practiced this method a great number of times for con- 
stipation, and, in the cases where great irritability of the 
sphincter existed, the constipation has been cured. In some 
few cases I have failed to cure. Of course, the general rules of 
health are laid down to these people to bring about a normal 
condition of the bowel. There are some general directions to 
be given for simple cases of constipation, which, if followed, 
will often result in a cure with but little if any medication. 
Among these I may mention the following : 1. On rising in 
the morning drink slowly a half -pint to a pint of water, either 
hot or cold — hot is preferable. 2. On retiring at night eat 
some fruit — say an apple, or a banana, or an orange, some 
prunes, or figs. 3. Dress according to the weather, but in the 
winter remember to dress warmly. 4. Pay special attention 
to the diet : by all means avoid eating any sweetmeats, can- 
dies, pastry, pies, etc., and remember that fruit that is not 
cooked is more digestible than fruit that is cooked. 5. Don't 
forget to walk a number of miles a day. 6. Avoid sitting or 
working long in one position. Avoid a sedentary life. 7. Have 
a regular hour for the bowels to move ; the best time is just 
after breakfast. 8. While at stool knead the bowels, espe- 
cially over the colon, with the palms of the hands, rubbing 
them firmly and forcibly from above downward. 9. Practice 
frequent bathing, especially in tepid or cold water, each bath 
followed by a brisk rubbing of the body. 

These health rules can be easily followed, and should be 
taught to all young people. Indeed, I have often thought that 
the most important branch that could be taught, in female 
boarding-schools especially, is physiology, and the subject of 
the most importance would be that of constipation. My books 
will show a record of numerous operations upon young girls 
ranging from twelve to fifteen years of age, suffering from im- 
pacted faeces caused by the studious habits at school. Rising 
in the morning just in time to eat a hurried breakfast to get 
to the school-room, in order to prevent being marked absent, 






CONSTIPATION. 63 

and in their eagerness to capture a medal they sometimes 
lose their health. These girls often tell me that they did not 
know that it was necessary for their bowels to move with any 
degree of regularity. One young miss said to me that she 
thought once a week was quite sufficient. But suppose that 
a patient comes to us already suffering from a chronic consti- 
pation of the bowels, what are we to do for this class in a 
medical way ? First of all, we are to impress them with the 
absolute importance of observing these health regulations 
that have been mentioned. Our next duty is to take them 
off of the line of treatment which we will usually find them 
pursuing. In nine cases out of ten — or I would speak more 
correctly if I were to say in ninety-nine cases out of a hun- 
dred — we will find them taking a purgative every night. In 
addition to this, many supplement this plan by taking an 
enema. In a condition of obstinate constipation where pur- 
gatives are given, they tend to keep up the congestion in the 
rectum, to irritate the external sphincter muscle, to cause in- 
ternal haemorrhoids to bleed, and predispose to an ulceration 
of the gut. Therefore, by all means stop it. In regard to 
enemas I am also just as positive that they should not be used 
except by the order of the physician. This habit of distend- 
ing the bowel by large and copious injections of water after 
a while, by placing the muscular fibers on a stretch, induces 
an atony of the coat, and produces constipation. If hot- water 
enemeta are used, they very quickly produce congestion of 
the blood-vessels. So neither hot nor cold water should be 
thrown in any quantity into the bowel as a habit. We 
often find physicians prescribing a soap injection to produce 
an evacuation of the bowels, especially in children. Soap 
should never be brought in contact with the mucous mem- 
brane, for its effect is to dry the natural secretion of the mem- 
brane. If any injection of water is given let it be pure water. 
But the patient will say, "If you take me off my purgative 
and suspend the use of a syringe, my bowel Will not move at 
all." The first thing to do with this patient is to convince 
him that no great damage is done if the bowels do not move 



64 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

for several days. There are a great many people who believe 
that to have an evacuation once a week is sufficient ; there are 
others who believe that it is necessary to have from one to 
three evacuations every day. One view is as absurd as the 
other. I remember that an old and honored physician once 
said to me that if his bowels moved freely in the morning he 
was sure that he would not die that day. Now, there was 
some reason in what this man said, as far as health was con- 
cerned ; but it would be more of a mental depression than 
otherwise that would occur if what he looked for did not take 
place. Having the patient, then, under your control, and will- 
ing to abide by what you say, affirm positively that chronic 
constipation can not be cured in a day. Above all, you are 
to look to their habits and instruct them accordingly. First, 
I would give a free purgation by the aperient plan — say a small 
dose of salts, a teaspoonful to a large glass of water, taken 
every one or two hours until four or five doses are taken. In 
addition to this, wash out the rectum once with a large injec- 
tion of cold water. Now, to begin with, if they are senemic 
or emaciated, they should be put upon a good tonic and con- 
structive. I think we fall into error here in prescribing the 
preparations of iron for these people, especially the muriated 
tincture of iron. These constringe by their action and prevent 
the normal secretion of the mucous membrane. The only 
preparation of iron that is suited to these cases is the sol 
albuminate iron, and the best made, in my opinion, is that of 
J. Flexner & Co., of this city. In lieu of all these ordinary 
tonics I would suggest as an excellent builder Trommer's ex- 
tract of malt, with cascara sagrada combined. This company 
puts up an excellent preparation of the kind. Very many 
cases in my hands have been relieved by this simple method 
of treatment. If it is desirable to give more of the cascara, a 
preparation can be made consisting of equal parts of glycerin 
and cascara sagrada, with directions to take one half tea- 
spoonful at bedtime ; and, if this does not suffice, repeat it in 
the morning before breakfast. This agent I am sure adds tone 
to the bowel, and does not act in the ordinary way of a purga- 



CONSTIPATION. 65 

tive. In my hands it is an excellent agent in the treatment 
of constipation. Several years ago the glycerin treatment per 
rectum came into vogue. In some few instances it has been 
effective in my practice. Many firms put up a beautiful 
glycerin suppository, and by inserting one of these an action 
from the bowel will usually take place in from five to fifteen 
minutes. It is an excellent idea when traveling for the patient 
to take a box of these suppositories with him because of their 
convenience. I have not found, however, that they are as 
curative as they are said to be by some, but they are well 
worth a trial. The injection of one drachm of glycerin 
into the rectum will accomplish the same result, but the 
method is not as convenient as the suppository. There is 
an idea prevalent with the people, and I believe that the phy- 
sician is responsible for it, which I am sure is erroneous, and 
that is that the bowel should only act at one certain time 
during the day. I have known patients so imbued with this 
idea that if their bowels desired to act at any other time they 
would bend their energies to prevent it. They should be in- 
structed that, while it is proper to have a regular hour for 
defecation, it is also proper to let the bowel move whenever 
it so desires. Nevins holds that in all cases of chronic con- 
stipation there is a considerable degree of chronic irritation, 
and subacute inflammation of the csecum and colon, as also 
the surrounding cellular tissue. This condition not infre- 
quently becomes acute, and is diagnosticated as typhlitis. 
The result of such acute inflammation is a reflex inhibition of 
peristalsis, and for its relief purgatives are usually exhibited 
with partially successful but temporary effects. In such 
cases he employs twelve grains of Dover's powders, at bed- 
time, combined with turpentine stupes over the belly, and 
secures a good evacuation by morning. This, with care- 
ful regulation of the diet, and the avoidance of purgatives, 
soon overcomes the costive habit. The philosophy of the 
treatment is explained, that by the opium the irritated bowel 
for the time is put at rest, and is enabled to regain its tone ; 
while the ipecac, by stimulating the secretions of the intes- 



QQ DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

tinal mucous membrane, assist the natural progress of the 
strengthened peristalsis. To a certain extent I quite agree 
with this view of Nevins, but I would make an addition to 
the treatment of such a case. It has been my experience in 
dealing with cases that similated or were believed to be 
typhlitis that the aperient method of treatment was at- 
tended with the best results. In other words, if ther"e has 
been an accumulation of faeces in or near the csecum, that it 
should be washed out by aperients. After this has been ac- 
complished, then the administration of Dover's powders, com- 
bined with the turpentine stupes, would, in my opinion, be 
an excellent plan. In many cases of constipation I have 
found that the administration of small doses of bichloride 
hydrargyrum accomplished a great deal — the one fortieth of a 
grain, given as a little pellet three times a day, until the effect 
is noticed. 

There are many cases where it is necessary to tone up the 
nervous system, and no agent so beautifully does this as 
strychnia. A favorite formula with physicians is what is 
known as the aloin-strychnia and belladonna pill. My objec- 
tion to this pill is that it begets a habit. We are using a 
purgative constantly when we have advised against such a 
course ; therefore, I would rather administer the pellet with 
the aloin left out. The use of electricity has been strongly 
urged by some as a great agent of good in these cases. I 
must say that in my practice the effect of it has been entirely 
nil. A better course of treatment I have found in a general 
massage. If there is an experienced hand at the business 
within reach, it would be well to have the patient undergo 
a thorough course of treatment, and in many instances it 
will be found that not only is the general health improved, but 
that the constipated habit also is benefited. I often think 
that in constipation, as in many ailments of the body, if the 
general health is looked after, the ailment will take care of 
itself. In no class of disease is this more self-evident than 
in diseases of the womb. The old-time practitioner was in 
the habit of doing much local treatment for these affections, 






CONSTIPATION. 67 

but to-day more reliance is placed on building up the general 
constitution, and it is needless to say that the results are 
much better. So I am inclined to think of many cases of con- 
stipation. Young ladies are frequently in the habit of eating 
ad libitum of candies, etc., and when they are brought under 
our observation the whole glandular system is more or 
less deranged. Of course, they are constipated. If they are 
directed to leave off the candy, and substitute beefsteak, the 
general health will rapidly improve, and the constipation dis- 
appear. 

I am frequently asked to give a good prescription for con- 
stipation. As a rule, I do not believe in such prescriptions. 
Every individual case must be diagnosed and treated upon 
its own merits. In these patients we frequently find, as I 
have said, an anaemic condition and general debility, with 
neurotic tendencies. For such a case, as a general tonic and 
reconstructive, the following will be found to answer a good 
purpose : 

!Ejfc Strychniae gr. ss. 

Hyd. bichloridi gr. ij. 

Liq. potassii arsenitis 3 ij. 

Acid, hydrochlor. dil., 

Tr. f erri chloridi aa 5 ss. 

Glycerini, 

Elix. simpl aa § ss. 

Aquae destillat q. s. ad §viij. 

M. Sig. : Two teaspoonfuls in a little water half an hour 
after meals. 

This class of patients should be taught to observe the 
rules of hygiene, to pay special attention to the diet, and to 
avoid all stimulation in the way of alcoholic or malt liquors. 

As we have stated, there are three receptacles of the faecal 
mass, viz., the caecum, sigmoid flexure, and rectum. We are 
too often inclined to believe that the rectum proper is ac- 
countable for constipation, admitting that the pressure which 
is natural here from delayed evacuations of the bowel is a 
source of constipation ; arguing from the same standpoint, we 



68 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

are forced to the conclusion that the sigmoid flexure is more 
accountable, for the reason that the faecal mass is lifted back 
into the flexure if the calls of Nature are not heeded, and 
that by this time its watery constituent is absorbed, and 
leaves in the sigmoid the faeces in a dried condition. There- 
fore, it is no wonder that this proves to be an irritant, and 
causes trouble by its presence. I would therefore impress 
the necessity of looking to the sigmoid in treatment of 
chronic constipation. We adopt means to bring back the 
tonicity of the muscular coat of the rectum, and yet forget 
that this same quality is wanting in the sigmoid. Believing 
this to be true, we must turn our attention to this, the seat 
of very common trouble. Admitting, then, that a congestion 
of the vessels, or even ulceration of the mucous membrane 
of the sigmoid, can take place by this accumulation of faeces, 
we are led to inquire if the flexure proper can be treated. 
For a long time I was under the impression that it could 
not, and, if we had yet to rely upon the old method, this 
opinion would still be true ; but since the introduction of the 
Wales bougie, it can be done with a very great degree of suc- 
cess. This bougie was devised by Dr. Philip S. Wales, of 
Washington, in 1876, with a view, as he says, of obviating all 
possible objections to mechanical dilatation of stricture ; and 
although in an article written concerning its use in that dis- 
ease, he does not seem to consider its utility in other affec- 
tions, yet in my practice it has been of the greatest value 
in treating diseases of the sigmoid flexure and colon. I 
think the profession is indebted to Dr. Wales for devising so 
excellent an instrument by which we can accomplish this. 
The bougie is made of pure gum, very flexible, perfectly 
smooth, and varying in size. A conduit runs through the 
center, and terminates in the point of the bougie, for the pur- 
pose of commanding a stream of water which might be re- 
quired at any moment to facilitate the introduction of the 
instrument. The points of the bougie are made in various 
shapes, with a view to meeting the necessities of special cases. 
The surface of the instrument is perfectly polished, which, 



CONSTIPATION. £9 

by reducing friction, increases the facility of introduction. 
The method of introducing the bougie is simple. For treat- 
ing the sigmoid flexure or throwing water into the colon, I 
am in the habit of using a No. 5 attached to the end of a 
Davidson's syringe. The patient, after the bowels have been 
cleaned out by injection, reclines on the left side, with the 
thighs flexed, the surgeon's right hand grasping the bougie 
close to the anus, the left hand steadies it, and the bougie is 
gently pushed beyond the sphincter. A moderate force only 
is necessary to have it enter three or four inches. I then 
throw one syringeful of tepid water through it, and if the 
point has been arrested in the folds, or even against some 
faeces, it is enabled to pass on into the sigmoid flexure. No 
greati amount of water should be used, because it would have 
to be evacuated ; and no special force should be employed, 
because of the danger that might follow. 

In these cases of constipation where it is supposed that 
the sigmoid flexure is at fault, I am in the habit of first in- 
jecting the flexure with a large quantity of hot water. From 
this I gradually inject cooler water, until at last fresh spring- 
water, or that which has sat upon the dresser overnight, is 
injected. I then prescribe the fluid hydrastts; a tablespoon- 
f ill diluted in a small cup of water, thrown into the flexure, 
and allowed to remain there. This I repeat every second 
day. With this I alternate by using the following : 

$, Sweet almond-oil one pint. 

Iodoform one drachm. 

M. Sig. : Inject one ounce each night at bedtime. 

It is best in using this preparation to throw an addi- 
tional syringeful of hot water behind it, from the fact that it 
drives the oil out of the syringe. This treatment kept up for 
a few weeks usually eradicates the trouble in the flexure, and 
at the same time aids the evacuation. Of course, the part 
directly involved in chronic constipation is the large intes- 
tine. Landois says that the contents pass through the small 
intestines in three hours, and through the large bowel in 
twelve hours. The contents are liquid in form as they are 



70 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

poured through the ileo-csecal opening. In the colon they 
are exposed to the open mouths of the Lieberkuhn follicles, 
which take up the digested portions which have escaped the 
absorbents above. The longer the contents are exposed to 
the absorbents of the colon, the watery portions will be ex- 
tracted, and the more solid will be the mass. The secretion 
from the large intestine is mostly mucous and this lubricates 
the walls. There is not sufficient watery secretion from this 
part to modify the consistence of the fseces. Now, if the mass 
remains in the colon or the sigmoid flexure longer than this, 
it interferes with the natural order of things, and therefore I 
have suggested that we have an abnormal condition both in 
the colon and the sigmoid flexure, as well as the rectum, in 
these cases. The peristalsis in the large intestine depends 
very much upon that in the small intestine ; therefore I have 
believed that, when it is deficient in the large intestine, it 
should be aided by the injections named. We fall into error 
by prescribing under these circumstances an injection into 
the rectum through the ordinary enema- tube. Of course, this 
falls short of the part intended, in that it lodges in the pouch 
and accomplishes very little good. If thrown into the sig- 
moid flexure and the patient allowed to rest on the left side 
with the buttocks elevated, the injection will run into the de- 
scending colon, and anything short of this will not accom- 
plish the desired effect. If we expect to cure constipation, 
we must first recognize the cause of it, and the cause may 
not rest altogether in the larger bowel. Purgatives under 
the conditions that I have named do harm rather than good, 
and should never be relied upon in treating any case of 
constipation. It has been suggested by some that in these 
cases we can bring about the required effect by the use of 
electricity. Theoretically this would appear to be an ad- 
mirable remedy, but practically it is a failure, at least it 
has been in my hands. I would much rather rely upon 
medicines which act directly on the motor center of the 
muscular coat of the intestine — this center being, according 
to Landois, the plexus my enter icus of Auerbach, located 



CONSTIPATION. 71 

between the two layers of muscular fibers in the wall of 
the bowel. 

There are many medicines that are said to act upon the 
motor centers ; among them can be named aloes and nicotine. 
There is an old idea prevalent that the taking of aloes induces 
to a congestion of the veins of the rectum. So sure am I that 
properly administered it has directly the opposite effect, that 
it is a favorite of mine where a drug is required in treating 
constipation. As to nicotine, it is proverbial with the smoker 
that a cigar after breakfast will frequently cause an evacu- 
ation of the bowel. I have recommended strychnia in the 
treatment of this trouble, because it acts indirectly through 
the cerebro- spinal nerves. The impressions are carried to the 
plexus myentericus, through the cerebro-spinal nerves, which 
stimulate this center, and contraction of the muscular coat is 
the result. One of the greatest mistakes in treating constipa- 
tion is the giving of tonics too freely. Large doses of iron,, 
as an example, will counteract the very effect that we are 
trying to induce. As a habit it is very well to tell the pa- 
tient to drink freely of cold water, or perhaps of very hot 
water, before breakfast, or at bedtime. Mineral waters can 
be taken ad libitum, such as Vichy, Saratoga, and in obsti- 
nate cases the Carlsbad. They tone up the bowel without 
doing any harm. If the liver is at fault, it must be looked 
after and the proper remedy administered. As a cholagogue 
nothing is better than the small doses of the bichloride of 
mercury, as has been stated. If atony of the coat is due to 
centric disease of the nervous system, we must direct the 
remedies there, but at the same time keep the rectum and 
colon entirely free from accumulations. 

It must be remembered that constipation may arise from 
a condition of the stomach inducing dyspepsia ; and, besides 
that, there are many cases of this trouble which result from 
intestinal indigestion. There are others where the cause 
may be traced to a gastro-intestinal catarrh, a chronic catarrh, 
or perhaps an ulcer of the stomach. Either one of these con- 
ditions being diagnosed, the patient should be referred to the 



72 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

general practitioner, because, if the ordinary remedies and 
treatment are used for this affection, no good will be accom- 
plished. Dr. Theodore Flatau, at a meeting of the Berlin 
Medical Society, in a paper read on the treatment of chronic 
constipation, gave a novel method of treatment. He states 
that the method is easiest of application in those cases 
which are the result of chronic obstipation and relaxation of 
peristalsis, a chronic proctitis, and the prolapse of a greater 
or less portion of rectal mucous membrane at the anus. The 
nates are widely separated, and after washing the exposed 
mucous membrane, enough powdered boric acid to cover the 
tip of a knife-blade is strewed upon or rubbed into it. In 
patients in whom the rectal mucous membrane is not visible 
the powder must be insufflated. It is desirable that the 
treatment should be carried out by the physician himself 
the first few times. Each application requires about three 
drachms (forty-five grains) of boric acid. The patient must 
afterward rest quietly so as to give the powder time to be 
taken up. He says that in from one half to three hours we 
will be almost certain to observe pretty strong peristaltic 
movements along the course of the colon, and probably also 
along the small intestines. About the prompt action of the 
remedy he says there can be no doubt, for he has demon- 
strated it in a number of cases. In the first few days of 
treatment an evacuation occurs quite regularly three or four 
times a day. It is of importance to tell the patient to obey 
the inclination to defecate, which is weak at first, for, if this 
be not done, the stronger peristaltic movements may also be 
overlooked. A so-called tolerance of the drug is not estab- 
lished. Among the cases which plainly presented the indi- 
cation noted above, the author has never known the remedy 
to fail him. On the contrary, he has been able to see not 
only a permanent strengthening of the muscular structure 
of the colon, but also a return to normal peristaltic activity 
where the treatment was carried out for some time, and the 
intervals between the single applications were gradually in- 
creased. In proof he submits some brilliant results. The 



CONSTIPATION". 73 

author assumes that a similar stimulation of the mesenteric 
plexus is brought about by the irritation set up by pure boric 
acid applied to the rectal mucous membrane, as is accom- 
plished under normal circumstances by the voluntary move- 
ments of the levator and sphincter ani, or of those set up by 
the passage of the electric current. In answer to the objec- 
tion that may be brought up against the long-continued use 
of boric acid, that its absorption may prove harmful, the au- 
thor brings to mind the experiments of Neumann, of Dor- 
pat, the therapeutic results from the internal administration 
of boric acid reported by Rosenthal, and the case of Molo 
Denkow. 

I have given this treatment a fair trial. In all lesions 
around the anus from pruritus, fissure, eczema, or wounds in- 
flicted, the boric acid is a favorite application of mine. In 
many instances I have been persuaded that the action has 
been as the author has stated ; anyway, as it is a simple 
method and can not result in any harm, it is well worth the 
trial in cases of constipation. The injection of large quanti- 
ties of water into the colon, known as the Hall treatment, is 
just at present greatly in vogue in this country. To show 
how erroneous his statements are : in a little pamphlet which 
goes with the treatment as sold, he states that he himself was 
cured of consumption by what he pleases to call his own 
method. It is also asserted that dyspepsia and its sympa- 
thetic evil effect on the throat, liver, heart, lungs, etc., can 
be eradicated by this manner of treatment. Indeed, he ap- 
pears to think that what he is pleased to call the engorged 
colon is responsible for many, if not all, of the ills of the 
flesh, and therefore it is used as a remedy for them all. He 
says that he began by purchasing a common bulb syringe, 
and at the first attempt forced a pint of water into the rec- 
tum, though with considerable difficulty ; but, small as was 
the quantity, its discharge produced a more beneficial, rest- 
ful, and exhilarating effect over the whole organism than 
that of any cathartic ever taken. The next evening he dou- 
bled the quantity, forcing a full quart of warm water into 



74 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

the colon. Accordingly, two evenings thereafter he resumed 
his task, measuring out two quarts of water ; to be comfort- 
able to the hand, and to increase its lubricating quality (?) he 
added a little soap, owing to this increased quantity, which 
required a still greater effort to inject it, particularly in forc- 
ing it past the sigmoid flexure, or first bend in the colon, 
just above the rectum. At the next effort he injected three 
quarts of tepid water. Three evenings later he injected 
slowly four quarts of water ! 

The student of anatomy will see at once the errors in this 
statement. Of course, we all recognize that a thorough clear- 
ing out of the intestinal tract is a good preliminary to the 
treatment of almost any disease, yet we know how absurd it 
is to talk of the injection of water into the rectum curing any 
pathological condition in the lungs. As far as the washing 
out of the bowel is concerned, it can be much more easily 
and effectually done by a good aperient than by any injec- 
tion. Again, as I have stated, to accomplish the good even 
that he claims, or, more to the point, what we claim, the 
washing out of the colon and preventing the impaction, the 
water should be thrown into the colon and not into the rec- 
tum, as he suggests. Forcing the water from the rectum 
into the sigmoid flexure, and farther along into the colon, by 
depositing it in the pouch of the rectum, can not be accom- 
plished except by a slow process, and the syringe does not 
aid it. If it is the absorption of the water that we want, the 
colon is the proper place to have it absorbed. His most re- 
markable advice is. in recommending this treatment to per- 
sons in the most exuberant health, at least every third night, 
in order, as he says, to keep pure and uncontaminated the 
circulation of the vital fluid of the system. (?) 

In a paper read before the Mississippi Valley Medical 
Association, September 26, 1888, by Dr. George J. Cook, he 
said : "In the autumn of the year 1882, while using large in- 
jections of hot water to remove a fsecal impaction located in 
the ascending colon, my attention was called to the rapid ab- 
sorbing powers of the colon, and also the effect as a diuretic 



CONSTIPATION. 75 

of water thus introduced in large quantities into the circu- 
lation. This patient, to relieve intense pain, excited by the 
hard faecal mass, had taken freely of morphine and was thor- 
oughly under its influence when I first saw him — a good con- 
dition in which to begin the treatment, which consisted in, 
viz., the injection of water to soften the obstruction. I threw 
into the colon about a gallon of water, at a temperature of 
115° F., and instructed the patient to retain it as long as pos- 
sible. Next morning, when I called, the patient in alarm 
informed me that the water had not yet passed away, and 
during the night he had had great trouble with his bladder, 
having to relieve it every hour. The quantity of urine passed 
during the night was almost equal to the water injected during 
the evening before. The hot water had also the effect of re- 
laxing the colon and relieving pain, he having no occasion to 
take more morphine during the night. Having to repeat the 
injection several times before the obstruction was removed, I 
closely observed the result. Each time before repeating the 
injection I gave a full dose of morphine to quiet peristalsis, 
and with this preparation the colon retained the water with- 
out pain or inconvenience to the patient. It was rapidly ab- 
sorbed, and within eight or ten hours from three to five pints 
of urine would be passed, varying in proportion to the quan- 
tity of water used. His skin was moist, but no diaphoresis 
occurred. Since that time I have had occasion very many 
times in my practice to use large injections of water in the 
colon for various diseased conditions, and have abundant op- 
portunity of observing the repetition of the facts stated in 
connection with the first case in regard to the rapid absorp- 
tion of a large quantity of water by the colon, and its imme- 
diate effect as a diuretic. I have injected water in a perfectly 
healthy colon to observe what quantity could be held without 
the use of morphine to quiet peristalsis, but never succeeded 
in having a quantity held and absorbed that would materially 
affect the quantity of urine. When we wish to place the colon 
at rest to retain and absorb water, it is best to give the mor- 
phine a half hour or an hour before injecting the water, and 



76 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

the injection should be made directly into the colon and not 
allowed to flow through the rectum by the use of the ordinary 
syringe. The best instrument for the purpose is the Wales 
rectal bougie, introduced until the end rests in the sigmoid 
flexure ; then, with the syringe attached to the outer end, the 
colon can be filled without distending the rectum. The water 
should be made to flow very slowly ; the fountain syringe is 
the best for the purpose. The temperature that I have found 
most agreeable is from 110° to 115 F. The desirable position 
for the patient is on the back, with the pelvis raised slightly. 
This enables you by percussion to trace the water as it tills 
the colon, to tell when it reaches the caecum, and the amount 
of distention. If there is no obstruction the water will flow 
freely around the colon, which should be only moderately 
distended— usually from three to five pints can be used at an 
injection. The normal colon is slow to respond to excitants 
compared with the rectum, the latter being a much more sen- 
sitive part of the large intestine, having a nerve supply direct 
from the spinal cord. When the healthy rectum is distended 
it responds quickly and dispels its contents, and this excita- 
tion will be transmitted to the colon and cause it to act more 
promptly ; but when the normal colon alone is distended by 
injection, it requires from fifteen to thirty minutes for peris- 
talsis to be excited. This is the special reason for throwing 
the water into the colon when we want it retained. After 
free diuresis was caused in this way in a healthy person, I ex- 
amined the urine to determine if the solids were increased 
during the twenty-four hours, but never found any increase 
in their amount, and reason would not indicate that there 
should be any increase in a person perfectly healthy." 

I have quoted Dr. Cook in extenso, for the reason that, 
instead of being a corroboration of Hall's ideas, it is really a 
refutation of them, Hall dealing with the body from a physio- 
logical aspect, or advising the use of his method when disease 
does not really exist, and Dr. Cook using the remedy only 
when a pathological or abnormal condition does exist. In 
other words, his investigations were in using large injections 



CONSTIPATION. 77 

of water for the purpose of washing out the colon and the sig- 
moid of an impaction of faeces. We have already stated what 
would be the result of such impactions. His observation is, 
then, that in this abnormal condition of the colon a rapid 
effect is had upon the kidney, partly from the fact that, owing 
to the disease existing in the mucous membrane, and that the 
water was injected into the colon, and not into the rectum, it 
had this effect upon the kidney. He also informs us that this 
effect is not had when the water is thrown in large quantities 
into the colon, and more especially into the rectum, when no 
pathological condition exists in them. To meet the condi- 
tion which existed in Dr. Cook's cases, we could heartily rec- 
ommend the plan — viz., to wash out the colon of any accumu- 
lation, or to have a good result upon a diseased surface ; but, 
as he informs us, this could not be accomplished in any other 
method than by throwing it to the seat of trouble. Now, to 
the contrary in the Hall method, this large amount of water 
is thrown into the rectum proper by the ordinary enema tube, 
and its effect is very different from the injection as practiced 
through Wales's bougie by Dr. Cook into the colon. It is 
absurd to say that this injection into the rectum will accom- 
plish any good to the general health when no disease exists. 
In the first place, this enormous quantity of water thrown into 
the pouch of the rectum distends its muscular walls beyond 
that of a normal capacity, and frequently repeated will cause 
a relaxation of the muscular libers, causing them to lose their 
tone, hence ending in an atony of the gut ; and when the in- 
jections are left off, to result in constipation. It is a well- 
known fact to the general practitioner that where a patient 
has been in the habit of using an ordinary amount of water 
as an enema it has induced this very state which calls for a 
continuance of the injection. The absorbing power of the 
rectum is not equal to that of the colon, and, consequently, 
if the injection is called for at all to meet any special indi- 
cation, it should be thrown into the colon and not into the 
rectum. Again, the secretion of mucus by the mucous mem- 
brane is of absolute necessity in aiding the faeces to pass 



78 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

quietly through the gut. Now, we know if there is a daily 
injection of water, especially in large quantities, either hot or 
cold, it interferes with the secretion. When the body is in a 
normal physiological condition, it needs no medicine. If the 
liver, or the stomach, or the kidneys are doing their proper 
duty, it is foolish to say that it is necessary to medicate them, 
anticipating disease. If the colon, sigmoid flexure, and rec- 
tum are doing their duty, it is just as foolish to say that they 
should be injected with large quantities of water to keep them 
from becoming diseased. I can quite understand that in 
febrile conditions, when the water is being rapidly taken from 
the system by the cutaneous and pulmonary evaporation, and 
the renal blood pressure is greatly lessened by the attraction 
of blood to the surface of the body, the kidneys often become 
inactive. In such cases, if a free diuresis can be excited by 
the introduction of water through the colon, it would be a 
good idea to introduce the water. In cases of continued 
fever, as suggested by Dr. Cook, when the tissues are being 
desiccated by the free evaporation and emaciation is progress- 
ing rapidly under the influence of increased temperature, and 
only a small quantity of fluid can be taken by the stomach, 
great good can be done by conducting water freely through 
the colon into the circulation. In these cases the blood-ves- 
sels are filled and the tissues again supplied with water, 
which will induce a free action of the kidneys and also other 
glands of the body, and wash out the waste material, the re- 
sult of rapid tissue change which takes place under a high 
temperature. I can also understand how such treatment, 
used after the manner of Dr. Cook, would benefit diseases of 
the kidneys. In renal hyperemia, when we scarcely dare to 
give a diuretic that is irritating or stimulating, it is safe to 
introduce water for its diuretic property ; or in acute and 
chronic parenchymatous nephritis, when the tubules are 
clogged with epithelial or waxy casts, the large quantity of 
water which can be made to flow through the kidneys in a 
short time by this method will wash out the casts and clear 
the kidneys. We also know that water absorbed through the 



CONSTIPATION. 79 

colon enters the portal circulation, and to reach the general 
circulation has to pass through the hepatic capillary system ; 
therefore, in some liver troubles, it might be beneficial. But 
it is a very different thing to say that this large amount of 
water should be made to pass through the kidneys when the 
tubules are not clogged with epithelial casts or anything else, 
but, instead, to make the kidney do double or triple duty in 
a state of health. Therefore, while I am inclined to com- 
mend the views of Dr. Cook, I am not prepared to admit that 
water, used after the method of Hall, can do any good ; but, 
to the contrary, I can see in it an agent that will do much 
harm. 



CHAPTER IV. 

ANTISEPTICS IN KECTAL SURGERY. 

At one time I seriously doubted if the antiseptic treat- 
ment would obtain in rectal surgery as in other operations. 
Since I have fully tried the precautions and rules in this de- 
partment of surgery I am persuaded that, with care and at- 
tention to details, the same advantages are to be obtained. 
Not only do we get quicker results by their use, but we also 
prevent septic infection, which sometimes follows wounds 
around the rectum. When we remember that it is not the 
size of the wound which controls the amount of sepsis, but 
the exposure to the cause, we can understand that the opera- 
tion on a simple pile, whether by ligature, clamp and cautery, 
injection or otherwise, may result in septicaemia, tetanus, etc. 
When we remember, too, the large amount of blood that goes 
to the rectum, and the close continuity of the glandular sys- 
tern, it is no wonder that a septic infection can and does take 
place from wounds inflicted in this locality. It is a fact 
worthy of note that persons suffering from a malignant affec- 
tion of the rectum die often of rapid sepsis. 

Tetanus is regarded to-day as a germ disease, and we no 
longer talk about "nerve irritation " as being the prominent 
factor in the disease. It is only necessary to refer to the au- 
thorities to see that many surgeons doing this special work 
have met with some death or deaths from tetanus. But it is 
a noticeable fact that since the antiseptic treatment has been 
observed in the surgical treatment of these diseases but few, 
if any, deaths from tetanus have been reported. Therefore, 
recognizing that erysipelas, pyaemia, and tetanus may compli- 
cate these operations, and knowing now that they are each 



ANTISEPTICS IN RECTAL SURGERY. 81 

due to infection, we can no longer doubt that, for the safety 
of the patient at least, the antiseptic treatment should be 
scrupulously practiced in each and every operation around 
the rectum. In the operating room I have the following arti- 
cles, to wit : 

Two earthen bowls, two earthen dishes, one irrigator, one 
bottle of Johnson & Johnson's bichloride-of-mercury tablets, 
one bottle of carbolic acid, one package of absorbent cotton, 
one rubber sheet, one bottle of ligatures (silk), one bottle of 
prepared cotton and gauze sponges, one bottle of iodoform, 
drainage tubes, one razor, one nail-brush, bandages, bichloride 
gauze, iodoform gauze, one jug of boiling distilled water, one 
waste-water bucket, twelve sublimated towels, one dozen 
safety pins, one teaspoon, one chloroform or ether cone, tubes 
of vaseline, one hypodermic syringe, one bottle of chloroform 
(Squibb's), one can of ether, sulphate-of-morphine tablets, 
brandy, nitrite of amyl. 

It may appear to some that this is a long list, and there 
are those who would question the necessity of some of the 
articles herein named. To such I would say that if any one 
article in the list is left out, the day may come to the doubt- 
ing surgeon when he will wish that it had been included. 
When I look back over my past surgery and remember the 
death of a patient from tetanus resulting from the ligation of 
internal haemorrhoids, I wonder, if I had remembered to have 
taken my little tablet of mercury, if she would be living 
to-day. 

To begin : I presuppose that the room, table, instruments, 
vessels, assistants, and myself have been made aseptic in the 
usual way. One earthen bowl contains the sponges in mer- 
curic solution (1 to 5,000). The other bowl holds the instru- 
ments in a three-per-cent solution of carbolic acid, and a 
dish the ligatures and needles. The irrigator is filled with 
the same solution of mercury as the first bowl. The rubber 
sheet is to drain the water, blood, etc. ; and the basin is to 
catch it. The ligatures are to be used, of course, in the op- 
eration, in tying piles, polypi, tumors, blood-vessels, etc. I 



82 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

have specified silk, because it is better adapted to all these 
operations than anything else. I designate cotton and gauze 
sponges because they can be easily made aseptic, and thrown 
away after using, this being safer than trying to disinfect a 
sponge. I use iodoform because I believe it to be the best 
surgical dressing yet devised. I say this advisedly, because I 
have tried in vain to find a substitute. My experience with 
the agent has taught me to believe with Billroth that "iodo- 
form exerts a great formative influence on the smaller vessels, 
and these soon begin to grow out and multiply, in an extra- 
ordinary manner, by constant production of offshoots and 
capillary loops. The energetic growth of living tissue seems 
to rob the microbes of their nourishment, and in the struggle 
for existence they succumb to the growing cells of the ves- 
sel walls." 

I also agree with Marcy when he says: "In a general 
way, I believe the great value of iodoform as a dressing lies 
in its extremely slow solubility, and that iodoform poisoning 
is far less common than generally supposed." But I do not 
agree with Stimson, who* says : "Instead of dusting iodoform 
in a wound, it is better to spray the surface with an ethereal 
solution of iodoform." I have been using the powdered iodo- 
form ever since it was introduced, in small and large wounds, 
and I have never seen any constitutional effect in a single 
case, nor any bad local effect except in two cases, and I am 
sure that in these it was due to an idiosyncrasy. 

To proceed : I use the drainage tubes when required. The 
razor is used in shaving the hair off the parts. Iodoform 
gauze is mentioned, because I invariably use it after operat- 
ing to dress wounds. I boil the water to kill the germs. I 
sublimate the towels because it is necessary. I have a tea- 
spoon for various purposes, giving hypodermics, etc. The 
safety pins are better than those of other kinds. A cone is 
kept prepared, because, if it is not ready, one has to be made. 
I use tubes of vaseline, because it is purer than when in cans. 
A hypodermic syrinre is needed, becausa you are likely to 
administer morphine. I specify Squibb's chloroform and 



ANTISEPTICS IN RECTAL SURGERY. 83 

ether, because I think they are the best. The morphine tab- 
lets are kept, because after these operations it is necessary to 
have them. I have suggested that brandy be convenient, be- 
cause it is often needed ; and, lastly, nitrite of amyl should 
be within reach in case of chloroform poisoning. 

I have run through the list, and I think that they are all 
necessary. The evening before doing an operation I have 
the patient take a purgative, and the next morning an 
enema. Just before going to the operating room a hot bath 
is given. On the operating table the parts are shaved 
and then washed with bichloride solution thoroughly. I do 
not think Gerster's suggestion, that an antiseptic sponge be 
pushed up the rectum and kept there until the operation is 
finished, is a good one. With the preparations named, and 
the rectum irrigated, the patient is now ready for whatever 
operation on the rectum or anus you are to do. If it be for 
piles, "all internal piles are tied, and all external piles are 
cut off." The wounds are dusted with iodoform and the gauze 
is softly packed into them, or laid over them. Cotton is then 
placed over the gauze, and a T-bandage applied. The dress- 
ing is not removed until the third day, when the bowels are 
moved. The parts then are dressed with a hot mercuric solu- 
tion, dusted with iodoform, and gauze, cotton, etc., applied. 
If the case be one of fistula in ano, all wounds are irrigated 
during the operation with the mercury solution, dusted with 
iodoform, gauze placed in, and a T-bandage applied. If 
these precautions be followed, the largest w^ounds will heal 
without a drop of pus. My assistant lately carried through 
six weeks of treatment a wound which was made by the re- 
moval of the entire left buttock, without a single drop of pus. 

I have said that the silk ligature is used in preference to 
any others in these operations. I should make one exception. 
In doing a colotomy, I am in the habit of stitching the gut to 
the abdominal walls with catgut, for the reason that it can be 
easily absorbed. A thin piece of rubber is then placed over 
the wound after dusting with iodoform. 

Therefore I affirm that much better results can be obtained 



84 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

in rectal surgery by using the antiseptic treatment than by 
not using it. 

Although a firm believer in aseptic surgery, I sometimes 
regret that the two terms are so closely allied ; for in teach- 
ing, especially, I have seen much confusion arise over them. 
I do not think that there is any middle ground in antiseptic 
surgery. I can quite understand how an antiseptic surgeon 
can be, and is, an aseptic one ; but as the term antiseptic 
must embrace chemical solutions, at least for elucidation, I 
can not be, strictly speaking, an aseptic one. I also know 
that many who have written on antiseptics say that it must be 
absolutely thorough in every detail, or it is worse than none 
at all. I can not agree to this. It is certainly better to be 
half clean than not clean at all. It is also better to observe 
two thirds of the antiseptic precautions than not to observe 
any of them. There are some excellent surgeons who insist 
to-day that they can get just as good results from doing an 
operation aseptically as antiseptically. In this list we find 
some gynaecologists especially, for the reason that all are 
agreed that the chemical solutions should not go into the 
peritoneal cavity, and some general surgeons affirm that 
wounds will do just as well when treated by a strict observ- 
ance of surgical cleanliness as when treated according to anti- 
septic rules. Now, I might agree that when union by first in- 
tention is anticipated, such result can be, and often is, ob- 
tained by aseptic practice ; but suppose on a subsequent visit 
it is found that the wound is septic; will the dressing of it 
under these circumstances, by the " surgically clean treat- 
ment," eradicate the pus, or prevent the existence of more ? I 
think not. Time and again I have directed my assistants to 
try the plan and observe results. It does not matter how hot 
the water is, or how cleanly the surroundings ; a wound that is 
septic will remain septic after dressing in that manner. In 
other words, I am satisfied that a wound healing by granula- 
tion will continue to discharge pus, unless treated by the. 
chemical antiseptic plan. A solution of the bichloride of mer- 
cury will not only prevent pus, but will also eradicate it after 



ANTISEPTICS IN RECTAL SURGERY. 85 

it has made its appearance. Of course, I wish to be under- 
stood as meaning that all the other precautions are to be ob- 
served. Now, unfortunately, nearly all the wounds inflicted 
around the rectum have, from the nature of things, to heal by 
the granulating process. If a fistula in ano, simple or compli- 
cated, is divided, the wounds heal from the bottom, save in the 
rarest of cases. If haemorrhoids (internal) are ligated, a base 
is left which must heal by granulating. If a growth, malig- 
nant or non -malignant, is removed from these parts, the same 
method of healing obtains. Again, because of the location, 
these wounds are more liable to infection, and, as in fistulous 
tracts, are already infected. I then claim that, to get the 
best results, the solutions, etc., which go to make up the list 
that I have named should always be in reach of the rectal 
surgeon. And I am also constrained to believe that when 
failure attends the desired results, it is more the fault of the 
surgeon than of the wound. If we are dealing with dirty sur- 
roundings, we must not only attempt to prevent the dirt get- 
ting into the sacred precinct of the wound, but also, if said 
dirt has already taken possession, we must sterilize it. To 
practice antiseptic surgery as it should be practiced is a very 
difficult thing to do, and requires much labor ; but I must 
submit that it is worth the labor. I like the term antiseptic 
better than " surgical cleanliness." It hits the nail more di- 
rectly on the head, and if we were to maintain that we are to 
be "surgically clean" in doing operations, who, I would ask, 
is so clean \ Would it not be a good idea to make a combina- 
tion, as it were, of the aseptic and the antiseptic plans and 
get as perfect and absolute cleanliness as possible, and then 
throw in the chemicals for good measure ? The surgeon to- 
day who claims to work under the strict aseptic idea will, if 
observed, be seen to be the very best of antiseptic operators. 
To such a one no argument need be addressed ; but I have 
been explicit, that I might be plain to the student who is a 
beginner in practice. Mr. Allingham can do a colotomy with 
equal dexterity, whether he makes the incision in the lumbar 
region or the groin. One less expert might select the ingui- 



86 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

nal region, because the operation is simpler, though perhaps 
not the best. A student who thought it unnecessary to 
select the most difficult plan of treatment for a wound would 
make himself content with a simpler plan, though less ef- 
fective. 

To conclude : I would say that although I might agree 
that in many operations chemical antisepsis could be dis- 
pensed with, I am persuaded that in dealing with the diseases 
incident to the rectum it is best to fortify yourself with the 
list I have named. The following scheme of the antiseptic 
method of wound treatment by Dr. Albert Hoffa, Privat 
Docent of Surgery in the University of Wiirzburg, which 
has been translated^ from the German by my friend Dr. Aug. 
Schachner, will be of great service in aiding the operator to a 
correct understanding of the subject : 

Aseptic Operation. Disinfection. — 1. Protection against at- 
mospheric infection. 2. Protection against contact infection. 
Practically all objects in the operating room are washed with 
a five per- cent carbolic-acid solution. 

(a) Disinfection of All Persons engaged about the Opera- 
tion.— -The same should, at least before a major operation, 
have taken a warm bath, together with a change of fresh 
linen. The hands demand special disinfection. These are 
managed after the precepts of Kummell or Fiirbringer. The 
main point is the thorough cleansing of the ungual region by 
means of a knife. Kummell then directs a washing and 
brushing of the arms and hands for from three to five minutes 
with potash soap and warm water, afterward a two-minute 
brushing with chlorine water, or a three- to a five-per-cent car- 
bolic solution (one tenth per cent sublimate). Quicker and 
equally as safe, cheaper and less straining upon the hands, 
is the cleansing method of Furbringer— cleansing of the un- 
gual region with a knife, a one-minute brushing of the arms 
and hands, especially the subungual spaces, with soap and 
very warm water ; then washing for one minute in eighty per 
cent of alcohol, and for one minute in two per cent of subli- 
mate, or three per cent of carbolic acid ; the hands are then 



ANTISEPTICS 1ST RECTAL SURGERY. 87 

either dried with a sterilized towel, or, what is better, allowed 
to remain wet. 

(b) Disinfection of the Operative Region. — The patients, if 
possible, are bathed several times before the operation, and 
then the operative field covered with a fomentation of a three- 
per-cent carbolic solution, or one tenth per cent of sublimate 
solution. Hairy spots are previously shaved. Immediately 
before the operation the shaven spot and surrounding parts 
are brushed and washed with potash soap, then rubbed off 
with ether or oil of turpentine, irrigated with one-tenth-per- 
cent sublimate or three-per-cent carbolic solution, and further 
covered with compresses dipped in one-tenth-per-cent subli- 
mate or three-per-cent carbolic solution. The environs of the 
field of operation are covered with disinfected hospital cloths, 
or, still better, with towels saturated with sublimate solution. 

(c) Disinfection of the Instruments. — The instruments 
should, if possible, be made of one piece of metal and with- 
out furrows. They are brushed with a five-per-cent carbolic 
solution ; then, if possible, sterilized in a current of steam, or 
thoroughly heated upon asbestos plates, or, where this is im- 
practicable, boiled in a five-per-cent carbolic solution, and 
during the operation kept in a three-per-cent carbolic solu- 
tion. According to Redard, the safest and most convenient 
disinfection is by means of compressed steam of 110° temper- 
ature (centigrade) throughout, in a Rohrbeek's digester, for 
from fifteen to twenty minutes. 

(d) Disinfection of the Sponges. — New sponges are pre- 
pared in the following manner : They are cleansed in soda so- 
lution, and immersed for twenty-four hours in a solution of 
permanganate of potash (1 to 500), whereby they become brown ; 
then bleached in a wash-bowl of water with the addition of 
ten tablespoonfuls (Hve ounces) of hydrochloric acid and fifty 
grammes (745 grains) of hyposulphite of soda. If thus 
cleansed, they are then thoroughly washed with hot water 
and potash soap, and kept in a five-per-cent carbolic or one- 
tenth-per-cent sublimate solution. Suitable vessels are pro-: 
cured for the purpose of keeping in readiness different 



88 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

sponges for every day in the week. Disinfection of infected 
sponges is best effected in this manner : They are allowed to 
remain for twenty-four hours in lukewarm water, or, if possi- 
ble, in running water ; then washed with soap and hot water, 
and then kept in five-per-cent carbolic or one-tenth-per-cent 
sublimate solution. Lawson Tait wraps the clean sponges 
in gauze, which acts as a filter, withholding the organisms. 
The sponges are advantageously replaced by gauze or balls of 
absorbent cotton. 

(e) Disinfection of the Wound.— Aseptically prepared 
wounds are seldom irrigated with constantly irritating anti- 
septic remedies. Their cleansing, when desirable, is best ef- 
fected by irrigation with sterilized water or a seventy-five- 
hundredth-per-cent solution of common salt. If the asepsis 
is not certain, then irrigation with a one-twentieth-per-cent 
sublimate or one-per-cent carbolic solution should be em- 
ployed. In operations within the mouth or about the blad- 
der or intestines, irrigations of salicylic acid (1 to 1,000), or 
boric acid two per cent, are most preferable. Lastly, iodo- 
form ether (1 to 10) is distributed upon the wound with a 
syringe. The secretions of the wound are removed through 
one of the enumerated means of drainage. 

Antiseptic Operation. Disinfection as in Aseptic Opera- 
tions. — Frequently too concentrated solutions are employed, 
and thereby poisoning is produced. The so-called fractional 
sterilization is better, i. e., repeated irrigations of diluted so- 
lutions, as ten-per-cent sublimate, two-per-cent carbolic, two- 
and-one-half-per-cent acetate of alumina. After irrigation 
with the preceding solutions the wound should be sponged 
with a five- to a ten-per-cent chloride-of-zinc solution, or a 
ten-per-cent oxide-of-zinc mixture, or a mixture of equal 
parts of a three-per-cent carbolic acid and tincture of arnica. 
Perfect drainage should be had. Locally, lukewarm baths of 
one-tenth-per-cent sublimate, three-per-cent carbolic, or two- 
and-a-half-per-cent acetate of alumina solutions. As few as 
possible sutures, fomentations of three-per-cent carbolic solu- 
tion, suspension and immobilization of the wound. 



ANTISEPTICS IN RECTAL SURGERY. 89 

Before closing this chapter I desire to call attention to the 
anaesthetics, both general and local, which the rectal surgeon 
is called on to use in doing his special work. In the majority 
of operations done on the anus and rectum it will be necessary 
to use an anaesthetic. They are generally painful of execu- 
tion, and the patient will insist upon having some form of 
anaesthesia produced. Generally the first question asked is 
whether we can use a local anaesthetic in lieu of chloroform 
or ether. Most people are aware of the discovery of hydro- 
chlorate of cocaine. Such excellent results have been at- 
tained in the hands of the specialist, notably the gynaecolo- 
gist, oculist, genito-urinary surgeon, and I may say the gen- 
eral surgeon, that the rectal specialist hoped for the same 
good results. I am sorry to say that in my hands at least it 
has not met such expectation. Outside of the danger to life 
— and all must admit that there is some danger, especially 
when used hypodermically— it has not been of much use in 
rectal surgery. In some cases, however, it can be used with 
some benefit. By throwing the agent into close proximity to 
a rectal abscess, it can be opened with but little if any pain. 
I am in the habit of taking the salt with me and of making 
my own solutions. In a case of abscess I take one half of a 
grain, dissolve in twelve or fifteen drops of woter, draw into a 
syringe, and throw it into the tissues alongside of the abscess. 
If sensation is not deadened in ten minutes, inject another 
half grain. Then waiting a few minutes, you will find that 
the cutting can be done without pain. If the case be one of 
simple fistula in ano, it can be divided freely, edges trimmed, 
etc., with but little distress. External haemorrhoids can be 
cut off by its use. Besides these simple operations it is of 
little utility around the rectum. If the fistula be a compli- 
cated one, if internal haemorrhoids are to be operated on, if 
the sphincter muscle is to be divulsed for any purpose, if a 
stricture is to be cut or a cancer removed, if the gut is to 
be handled at all, or the sphincter plays any part in the oper- 
ation, cocaine is of no use. I wish that I could report differ- 
ently, but such has been my experience with the agent. 



90 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

Operations on the Rectum under Whisky. — Several years ago I 
reported to one of the medical societies five operations under 
whisky for rectal diseases. I had noticed that some general 
surgeons had reported a number of operations, among them 
amputation at the thigh, under the anaesthetic property of 
whisky. I selected those cases in my practice who objected 
to the use of chloroform or ether, or where I myself thought 
them inadmissible. 

Case I.— Judge T. came to me suffering the most intense 
pain from an irritable ulcer of the rectum. He described his 
sufferings as terrible, coming on at every action of the bowels, 
and lasting for hours. He had been advised by his physician 
not to take an anaesthetic because of some heart trouble. He 
being firm in the conviction, and not wishing to take an anaes- 
thetic anyway, I suggested that he take whisky to its full 
effect. He was not a drinking man, but agreed to try it. 1 
sent him to his hotel, with directions to take two ounces every 
half hour until he had taken a pint. I should remark that 
the patient was a robust, healthy man, of about forty-eight 
years of age. I was detained at my office a little longer than 
I expected, so I arrived at his room behind time and found 
him in bed "dead drunk." By the aid of my assistant I 
drew him to the edge of the bed, introduced a rectal dilator, 
stretched it to its full capacity, then finished the job with my 
fingers. During the operation he grunted a few times, but 
did not move or realize what I was doing. I left him in 
charge of the assistant, and did not see him again until the 
next morning, when I met him in the rotunda of the hotel. 
He told me that he did not remember or know that I did any 
operation on him. He was entirely relieved and went home 
on the second day. The amount of whisky taken was twelve 
ounces. The guide to the amount is, of course, the effect. 

Case II was for a similar trouble in the person of a very 
worthy physician who lived forty miles distant. He was direct- 
ed to take two ounces every half hour, beginning in time to 
anticipate my arrival on the train. When I arrived I found 
him raising quite a disturbance in his room by his wild ges- 



ANTISEPTICS IN RECTAL SURGERY. 91 

ticulations and loud talk. I gave him another " stiff" drink, 
in a short time persuaded him to lie down, and in a few mo- 
ments he was sound asleep, when I completed the operation 
and left. He told me afterward that he did not suffer any 
pain ; indeed, did not remember that I was there at all. He 
drank about one pint. To get the full effect of whisky it 
must be given often and with regularity. 

The other cases reported acted very similarly, but were for 
other diseases of the rectum. The sleep is profound enough, 
and lasts sufficiently long to do any operation. In none of 
my operations was there shock either from the whisky or 
from the operation. It must be borne in mind, however, that 
such result might occur from using so large an amount of 
the agent. I think that in cases selected by good judgment 
whisky can be used in doing these operations, where chloro- 
form or ether is contra-indicated. 

Local ancestJiesia can be produced in the following man- 
ner, and in some cases — as in opening abscesses, cutting off 
external tumors around the anus, etc. — can be used with bene- 
fit, viz. : Use a spray composed of ten parts of chloroform, 
fifteen parts of ether, and one part of menthol. After one 
minute's application of the compound spray, complete or 
nearly complete ansesthesia of the skin and neighboring tis- 
sues is produced, and will last from two to six minutes. Dr. 
Ap Morgan Yance, of this city, in an article commending the 
ether spray for local ansesthesia, says : ik I have found ether 
the most suitable agent. Rhigoline is more volatile than 
ether, but is much more inflammable. The method of ap- 
plying the ether spray is the secret of success. The atomizer 
with two bulbs is better than the ordinary instrument with 
one, as with the former the spray is constant. The assistant 
manipulating the spray must understand the different steps 
of the operation, especially if it be complicated. The spray 
is thrown on the part for only a moment, when the knife can 
be used ; continue the spray at intervals or constantly in the 
incisions, thus making the superficial ansesthesia precede the 
knife to any desired depth, no pain being felt. The ether 



92 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

seems to have a haemostatic effect also, as less blood is noticed 
than in ordinary cases. The healing process goes on as well 
as usual, no retarding or other bad effects being noticed in 
my cases. I have done many tenotomies in adults and chil- 
dren, the patient experiencing absolutely no pain." 

The only objection that I have to the ether spray in rectal 
operations is, that when it comes in contact with the mucous 
membrane it causes intense burning. In selected cases in 
this region, where the membrane is not involved, this spray 
would be of much service. It has the advantage over cocaine 
that no danger attends its use. 

Chloroform and Ether. — I do not consider it necessary, nor is 
it my intention, to enter into any discussion as to the merits 
that one or the Other of these general anaesthetics possesses 
over the other, but no one subject can be of greater moment 
to the surgeon than the matter of anaesthetics. That there is 
risk in giving either chloroform or ether can not be denied, 
but it becomes the duty of the surgeon to assume that risk. 
It is a question, then, to him of great importance to decide, if 
decide he can, which is the safer of the two. There is much 
difference in opinion, or in practice at least. In the North 
and East in this country ether is given nearly exclusively. In 
the South and West chloroform is given the preference. In 
my own practice I use chloroform most frequently, because 
the operations do not require much time. If the operation is 
a prolonged one I usually give ether, not because I think it 
much safer, but rather to meet the common opinion. Not 
caring to enter into the pros and cons of the subject, I believe 
that it will accomplish much more good to submit the views 
of one of our most distinguished men on the subject. Dr. H. 
C. Wood, of Philadelphia, read an able article before the In- 
ternational Medical Congress of Berlin in 1890, entitled An 
Address on Anaesthesia. The general facts or principles in 
regard to anaesthesia that he considered as established were : 

1. That the use of any anaesthetic is attended with an ap- 
preciable risk, and that no care will prevent an occasional 
loss of life. 



ANTISEPTICS IN RECTAL SURGERY. 93 

2. That chloroform acts much more promptly and much 
more powerfully than ether, both upon the respiratory centers 
and the heart. 

3. That the action of chloroform is much more persistent 
and permanent than that of ether. 

4. That chloroform is capable of causing death by prima- 
rily arresting the respiration, or by primarily stopping the 
heart, but that commonly both respiration and cardiac func- 
tions are abolished at or about the same time. 

5. That ether usually acts very much more powerfully 
upon the respiration than upon the circulation, but that oc- 
casionally, and especially when the heart is feeble, ether is 
capable of acting as a cardiac paralysant, and may produce 
death by cardiac arrest at a time when the respirations are 
fully maintained. 

6. Chloroform kills, as near as can be made out propor- 
tionately, three to five times as frequently as does ether ; no 
doubt because it is more powerful in depressing the heart, 
but largely because it lets go its hold much less rapidly than 
does ether when inhalation ceases. Is it- not possible that this 
" holding on" is because it is less volatile than ether, and can 
we not here get a hint why chloroform is less deadly in the 
South than in the North ? 

The rules for treatment of accidents by the agents he 
concludes : 

1. Avoid the use of all drugs except strychnine, digitalis, 
and ammonia. 

2. Give the tincture of digitalis hypodermically. 

3. Draw out the tongue and raise up the angle of the jaw, 
and see that respiration is not mechanically done. 

4. Invert the patient briefly and temporarily. 

5. Use forced artificial respiration promptly, and in pro- 
tracted cases external warmth and stimulation of the surface 
by dry electro-brush, etc., and, above all, remember that some 
at least, and probably many, of the deaths which have been set 
down as due to chloroform and ether have been produced by 
the alcohol which has been given for the relief of the patient. 



94 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

I do not think that the space allotted here to these consid- 
erations of Dr. Wood could have been made to subserve so 
good a purpose in any other way. Differing from him as I 
do in some of the non-essentials, I agree fully and uncon- 
ditionally with him in the essentials. Although I have had 
administered in my practice ether and chloroform about 
three thousand times without accident, I never see them given 
without some fear, and yet surgery can not be pursued with- 
out their use. 



CHAPTER V. 

H^MOEEHOIDS. 

Description. — The hemorrhoidal veins distributed to the 
lower part of the rectum are very liable to become dilated 
and varicose — first, from the fact that valves are absent in 
these veins ; second, because of the erect position ; and 
third, because of the peculiar office of the rectum. Now, 
ordinarily this dilatation or varicose condition is called 
4 'haemorrhoids, or piles." I think that the doctrine that 
haemorrhoids are to be defined as varicosities of the anal or 
rectal vessels is wrong. Granting that both dilatation and a 
varicose condition of the veins of the rectum exist, this does 
not constitute a haemorrhoid. The treatment, whether pal- 
liative or operative, as laid down for haemorrhoids proper, 
could not be properly given. There must be a further patho- 
logical change to constitute the haemorrhoidal affection. That 
this is the incipient condition, or rather the preceding con- 
dition, which tends to and may culminate in haemorrhoids, is 
correct, but the full changes which take place should be con- 
sidered and recognized before this term is used. Because of 
the distended condition of the veins by blood which by some 
obstruction is held there, a congestion is induced, and because 
of the friction to which they are subjected and the retention 
of the blood in the parts, an inflammatory exudate takes place 
in the tissues, and a veritable tumor is the result — one that 
can be seen, is well defined and can be handled, is firm to the 
touch, and grows by plastic infiltration. When the plexus 
beneath the mucous membrane within the external sphincter 
is thus affected, the haemorrhoids are called internal. When 
the veins outside the muscle are affected, the haemorrhoids are 



96 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

said to be external. In other words, when haemorrhoids are 
inside of the sphincter and protrude at stool, and can be re- 
placed and held within the sphincter muscle, they should be 
called internal. When the tumor is on the outside of the 
sphincter muscle, and can not be pushed inside, or retained 
if pushed within, it should be called external. Now, there is 
a mixed variety, which is a combination of an internal and 
external hemorrhoid. It takes in the verge of the anus, and 
is partly covered by mucous membrane and partly by true 
skin. It is well to recognize this classification, for the treat- 
ment depends upon it. 

External Hemorrhoids. — I believe all authors distinguish two 
kinds of external piles : first, a sanguineous tumor ; second, 
a cutaneous outgrowth. The first consists of the enlargement 
of a piece of skin near the margin of the anus, generally of a 
rounded form, of a soft feel, and a livid or blue color. Now, 
this is said to be a coagulum of blood, inclosed in a cyst, or 
rather in a dilatation of the vein, and that when we cut into 
it we evacuate this clot of blood. I am constrained to differ 
with those who insist that this is the condition at the seat of 
trouble. I am sure that, if the proper dissections are made, 
these clots of blood will usually be found outside of the vein- 
wall, not inclosed in a cyst, but lying in the tissues proper. I 
believe, then, that a rupture of the vein-wall takes place in 
many of these cases at least, which constitutes this variety of 
external haemorrhoids. 

Second : The cutaneous outgrowth, or second form of piles, 
I do not believe to be excrescences, but rather an enlargement 
of the superfluous tags of skin sometimes found around the 
anus. In other words, those having a smooth surface around 
the anus will not have this variety of pile. It is caused by an 
inflammation of the tag proper, enlarged by the inflammatory 
deposit. Anything that would act as an irritant in this neigh- 
borhood might excite to that condition, and they are desig- 
nated, along with the other variety, external haemorrhoids. 
The affection is a very common one, and, I might add, a very 
painful one. In so far as the last symptom is concerned, it is 



HAEMORRHOIDS. 97 

much more decided than in internal haemorrhoids, for pain in 
internal piles is not a factor unless they are irritated or ulcer- 
ated. Therefore, a person may suffer for many months, or even 
years, with internal haemorrhoids and complain of but little 
pain ; but, on the contrary, pain is the first, the most promi- 
nent, and generally the only symptom of the external variety. 
Therefore it is useless and out of place to say to the patient 
who comes to you for treatment with this form of trouble 
that he is not suffering with the most important kind of 
haemorrhoids. To the patient they are of decidedly more 
importance than any other form of pile that is met with. 
I do not believe, as asserted by some, that they are as com- 
mon as or more common than internal haemorrhoids. I am 
sure that I have treated ten cases of the internal variety to 
one of the external. 

As to the causes of the affection, it is very hard to trace 
them. The sanguineous tumor, I am satisfied, is often pro- 
duced by straining at stool ; but the inflammatory tag, con- 
stituting the second variety or external piles, I do not believe 
is produced in this manner. I do not believe, either, that 
constipation has as much to .do with this trouble as is thought 
by some. If there is an overloaded condition of the rectum 
with hardened faeces, a more or less impaction which would 
prevent the return of venous blood might result in an exter- 
nal pile ; but the simple atony of the gut, which oftentimes 
constitutes constipation, can not, in my opinion, produce it. 
Pregnancy we know to be a frequent and common cause of 
the affection, and in this case it is self-evident that it is 
brought on by pressure upon the venous distribution. There- 
fore women suffering from a confirmed displacement of the 
uterus are liable to this disease, and yet we will have persons 
consult us suffering from one or both forms of external piles 
who can not state the cause, nor can we find any reason for 
their existence. 

Symptoms. — The symptoms of external or internal piles vary 
greatly in different subjects. As I have stated, in external 
piles pain is the predominant symptom, increased on defeca- 



98 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

tion ; and in the second variety especially, what is to-day a 
small hypertrophy of a piece of skin, to-morrow amounts to 
a considerable enlargement. Now, this inflammation seldom 
goes on to suppuration. If it does, it is best to be on the 
lookout for a marginal fistula. External piles do not bleed. 
But if the physician expects to quiet down this inflammatory 
trouble which constitutes the affection in a few hours or a few 
days he will be very much mistaken. He will also be greatly 
deceived if he says to the patient : "Allow me to let this clot 
of blood out with the lancet, and you will be all right in a 
short while." It will be found that the knife excites addi- 
tional inflammatory action, which is about commensurate 
with the inflammation that is excited and kept up by the 
clot. It is just about as well to await the absorption of the 
clot by Nature and not to lance, as to lance and await absorp- 
tion of the plasma. Therefore, in speaking of the treatment, 
I shall object to the ordinary manner of dealing with external 
piles. 

External piles, when in a quiescent state, if in this con- 
dition they can be called piles, have no symptoms at all. 
This refers especially to the cutaneous pile due to flaps and 
tags of skin consisting of permanently hypertrophied folds 
of integument ; therefore it is only the inflammation of these 
tags or the blood tumor exciting to inflammation that causes 
any symptoms at all. When this takes place, as we have 
said, pain is the first symptom. There is also a feeling of 
heat and general uneasiness. The part is tender on pressure, 
and the reflexes are very great. It usually ends by the in- 
flammation subsiding, the absorption of the clot, and the 
return of the inflamed tag to its natural size. But the pa- 
tient is disturbed, first, by his own idea that he may be more 
seriously affected than he is ; secondly, by the pain that he is 
suffering ; and, thirdly, by his inability to attend to his busi- 
ness with any comfort. 

Case.— A distinguished jurist had been in bed for three 
weeks from the effect of two large inflamed external hemor- 
rhoids, At the end of this time his physician called me in 



HAEMORRHOIDS. 99 

consultation, and said that his patient had grown restless for 
the reason that these tumors would not diminish in size, and 
that while they existed he could not go to his office. Upon 
examination, I found one large tumor on each side of the anus. 
They were fully as large as a small hen's egg, very sensitive 
to the touch, and greatly inflamed. As this patient was es- 
pecially pressed for time by his business engagements, I sug- 
gested to his physician that we do an operation at once — 
removing the inflamed growths. • I contended that in much 
less time than it would take to quiet the inflammation by 
local application, the patient would be well of the wounds 
that would be made in removing the tumors. The physician 
consented, and the operation was done. In one week's time 
this gentleman was able to attend to his business, although it 
had taken three weeks' treatment prior to this, and yet they 
had not been reduced in size a particle. 

I might go on and cite many such cases, but I will make 
one suffice, with the declaration that I believe in all such an 
operation should be done. After repeated attacks of external 
piles, it will be found that where it has been a blood clot a 
predisposition has been established, and they are likely to 
have attacks oftener. If it is a cutaneous pile, repeated in- 
flammations will leave it enlarged ; therefore it is safer in 
both varieties to remove them rather than to palliate them. 
External piles are frequently but a symptom of some other 
disease, such as ulceration, fissure, internal haemorrhoids, 
pruritus, etc. Therefore, in operating for this external con- 
dition, the other disease or diseases should be eradicated if 
possible at the same time. 

Treatment. — I can not believe with Cripps that "the treat- 
ment of external piles is generally a very simple matter, 
seldom demanding operative interference, which should be 
avoided if possible." 

Although a few cases of simple piles outside of the sphinc- 
ter do get well in a very short while by local application, rest, 
etc., a great many cases require constant attention for a con- 
siderable length of time. Instead of an operation being sel- 



100 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

dom demanded, I am satisfied that in nearly every single 
instance, for the reasons that I have already named, if the 
patient would consent, it would be best to remove them, and 
the reasons which Cripps gives for "avoiding an operation, if 
possible," are to my mind chimerical. He says: "Wounds 
in the muco-cutaneous surface do not heal so readily as on 
the mucous membrane, and are apt, without care, to degener- 
ate into an ulcer difficult to heal." 

My experience has certainly been that wounds on the mu- 
cous membrane around the anus, or in the rectum, are much 
more difficult to heal than wounds inflicted outside of the 
sphincter muscle. And although I have removed hundreds 
of these growths by excision, I have never had the wound to 
degenerate into an ulcer at all. Authors usually advise that 
we be very careful not to cut away too much skin in this 
operation for fear that contraction will follow. Allingham 
says that you must not make a "clean sweep" of it, but take 
off a portion only. That which is left will contract in the 
process of healing. This seems to be the opinion of most 
men who have written upon the subject, but I must take ex- 
ception to the doctrine. If there is any one thing more than 
another that has caused me regret after doing an operation 
for external haemorrhoids, it has been that I did not cut away 
enough skin ; and although I deal pretty liberally in this 
matter, I have never yet had any contraction to follow my 
operations, either for external or internal haemorrhoids. I 
dislike the term "snipping off" the inflamed cutaneous ex- 
crescences. It does not express enough. I would rather say 
cut them off, or, what would be better, excise them. Now to 
illustrate : We will suppose that the case is one of a large in- 
flamed pile of the cutaneous variety. Instead of " snipping" 
off this growth, I first throw under it a half grain of the mu- 
riate of cocaine, and, waiting for five or ten minutes for its 
full effect, I catch up the tumor at its very base with a pair 
of four-pronged forceps. I draw it out firmly, and with a 
sharp bistoury divide the skin all around it, up to the 
mucous membrane on each side, then throw a silk ligature 



Plate I. 




HEMORRHOIDS. 101 

around its base, tie tightly, and cut off the tumor close to 
the thread. I tie, in cases of this kind, to prevent haemor- 
rhage, for very often it is excessive. I treat each large 
growth of a similar character in the same way. Unless the 
operation be done in this manner, and all of the tags re- 
moved, we will find that after the operation these tags, or 
portions of tags that are left, become enlarged by inflamma- 
tion, and on the second day are about as large as they were 
before we did the " snipping," and the other tags, even if 
they are quiescent, will take on inflammatory action after the 
inflamed one has been cut away, unless it has been done ef- 
fectually. Therefore my advice is, in removing external 
haemorrhoids, do it not recklessly, but sweepingly. If the 
variety of pile be that of a sanguineous venous tumor, the 
operation that is usually done is thus described by Ailing- 
ham : " Pinch up the tumor gently between the finger and 
thumb of the left hand, transfix its base with a curved bis- 
toury, and cut out ; at the same moment, by pressure with the 
finger and thumb, the clot may be extruded. Place a piece 
of fine cotton- wool at the bottom of the sac, and the opera- 
tion is completed. The pain soon subsides and the patient 
makes a speedy convalescence. The incision should be made 
in the direction of the radiating folds of the anus, and this 
allows more completely of the contraction of the skin." 

I know that this is the operation practiced from time im- 
memorial for this variety of external haemorrhoids ; but ex- 
perience has taught me that there is a better way to deal with 
them. The pain often continues for a number of days after 
this operation, caused, first, by the use of the knife, and, 
secondly, by leaving a portion of tissue that is already in- 
flamed ; and, moreover, the amount of inflammation has been 
increased by the cut. Indeed, I have never noticed a very 
great difference in time between quieting down these venous 
tumors by local applications and quieting them after letting 
out this clot. In lieu of this operation I do one in the follow- 
ing manner : After freezing the parts with a piece of ice, or 
with a bag of powdered ice and salt, or by the injection of the 



102 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

muriate of cocaine, as suggested in the other variety, I catch 
up this blood tumor with the four-pronged forceps by its very 
base. I then carry my knife completely around it at its bot- 
tom, thereby excising it. By so doing I thoroughly eradicate 
the trouble, and the wound heals without difficulty. Ailing- 
ham says : " If these sanguineous tumors are not interfered 
with, the blood in them in time will become absorbed, and 
they will ultimately form the cutaneous flaps already de- 
scribed." I am not able to disprove this, but I do not believe 
that this is the usual result. I am opposed to telling the 
patient suffering from external haemorrhoids that it is a sim- 
ple thing, for the reason that if an operation is done for his 
relief, rest and treatment of the wound are necessary, and I 
care not how small a wound is inflicted upon the body, under 
any circumstances, the patient should be advised to keep at 
rest. 

Since the carbolic- acid plan of treatment was begun, many 
itinerants and quite a number of regular physicians have 
fallen into the error of injecting external piles. I can not be- 
lieve that the wildest enthusiast in this plan of treatment ever 
intended that the plan should be used in external piles, for it 
will be seen at once that although the sloughing process might 
take place, and the pile be eradicated, the inflammation ex- 
cited would be great, the pain intense, and ulceration might 
possibly follow. Therefore, to those inclined to use this 
method of treatment in the internal variety, I would certainly 
say, do not extend it to external haemorrhoids. 

The common practice with physicians in dealing with this 
variety of piles is to use some ointment, and I believe that the 
reason for so many patients drifting away from the regular 
physician to the itinerant is because they have received no 
benefit from such prescriptions. To catch the ear of the com- 
mon people, these advertisers are in the habit of flaunting 
before their gaze in the public prints pile salves, etc. , that are 
specifies for the trouble. Fortunes have been made off of 
such stuff, and it is very rare if any of them ever do much 
good. I have seen fit to speak of the operative procedure in 



HEMORRHOIDS. 103 

external piles before dealing with the palliative just for this 
reason — viz. : that the ordinary treatment by salves, ointments, 
pastes, mixtures, etc., has proved of but little avail in prevent- 
ing or curing this class of affections. I know, too, that the 
question has been raised whether haemorrhoids, which include 
the external variety, should be operated on in the inflamed 
state. From both theory and practice, I will answer the 
question in the affirmative. In the first place, they are really 
not piles until inflamed ; therefore they need no treatment at 
all. We have shown the great difficulty in reducing the in- 
flammatory action of these growths around the anus. By an 
operation we remove not only the growth, but also the point 
of inflammation, and convalescence is hastened. How any 
harm can result from doing the operation under these circum- 
stances I can not understand, and my practice has taught me 
that only good follows this treatment, and I am positive in my 
advice that the operation should not consist in cutting off one 
half or two thirds of each prominent projection, but in cut- 
ting it all off. If one half is left, I am sure that the cicatri- 
zation of the wound does not obliterate the remainder. If ex- 
ternal piles are complicated with internal, it is my observa- 
tion that they are usually a part of them, and continuous with 
them ; therefore, in a word, I would say that external piles, 
as such, should be cut off at the same time that internal piles 
are ligated ; but if it be the mixed variety, the operation 
would differ somewhat, and therefore I will consider it in the 
chapter on internal haemorrhoids. 

There is no special danger in external piles. They very 
seldom suppurate, and they never bleed. If they should sup- 
purate, a marginal abscess, and perhaps a small fistula, may 
result, and sometimes an ulcer ; but I have very seldom seen 
any of these occur. After I have excised an external heemor- 
rhoid of either variety I dress it according to antiseptic rules, 
considering that the operation has been done in this way. I 
dust the parts with iodoform, then apply the bichloride gauze, 
over this the surgeon's absorbent cotton, and then a T-band- 
age. The bowels having been cleared by an aperient and 



104 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

the rectum washed out by an injection, I confine the bowels 
for two days, and do not take off the dressing in that time. 
Then allowing the bowels to move, after a thorough washing 
with the bichloride solution (1 to 5,000), or a ten-percent solu- 
tion of carbolic acid, I redress the wounds as in the first place. 
In a very few days they will heal. 

We have given the operative treatment for external piles 
first, because we believe, in the majority of cases, it is better 
to do the radical operation than to attempt any palliative 
treatment. I know that this is reversing the order of things 
as laid down in practice by many authorities, but my experi- 
ence has taught me that this is the best. Of these palliative 
treatments, the best, in my opinion, are those which could 
be more properly called preventives ; for, with the simple in- 
timation that one has a tendency to the hemorrhoidal dis- 
ease, there is a certain line of treatment which, if pursued, 
would go very far to prevent this affection. Ordinarily, we 
mean by palliative treatment that which will allay the symp- 
toms after inflammation has taken place. I believe that it 
is much better to forewarn one who is disposed to the trouble, 
so that external haemorrhoids, as a disease, are prevented. 

Usually some ointment is prescribed for the inflamed 
haemorrhoids. Chiefest among these is the application of a 
mixture of belladonna and opium ; or some astringent appli- 
cation, as the sulphate of zinc ; or acetate of lead in solution, 
etc. My experience with all such is that their results are 
negative ; for if I had to recommend anything to quiet the 
inflammatory state, which, as I have said, constitutes the 
hemorrhoidal trouble, I would recommend, in lieu of all 
these, the application of either heat or cold, as far as the 
reduction of the disease could be accomplished by any local 
application. But, as I have intimated, the reliance to be 
placed on such treatment is very little. I think the axiom in 
surgery that we must rest the part during the inflammatory 
state — I care not to what part it refers — is of more service 
than any other injunction, and it applies equally as well to 
external haemorrhoids as to anything else. Therefore the 



HEMORRHOIDS. 105 

patient should be advised to avoid active exercise. Next to 
this, the diet should be carefully watched. I am not a firm 
believer in the doctrine that any special article of diet influ- 
ences the rectum, and especially external haemorrhoids, but 
all such articles of diet that are stimulating — for instance, 
such things as contain pepper— should be avoided. The same 
can apply to drinks, and therefore it is best for the patient to 
avoid either alcohol, beer, or wine during the time that he is 
affected. It is said that smoking exercises a peculiarly dele- 
terious effect upon external haemorrhoids. Why this is so I 
can not quite understand, and yet it is a truth that I have 
demonstrated in a number of cases. Therefore it is best to 
advise the patient to leave off his cigars or pipe. Then, as 
has already been suggested, the application of heat, not only 
locally but also to the entire body, should be advised. I care 
not where the local inflammatory action is, after one has 
taken a hot bath and the blood is more equally distributed, 
he feels better, freer from pain caused by the inflammation 
or congestion of the parts. But if heat applied locally does 
not feel pleasant, then I tell my patients to use a cold appli- 
cation to the parts. Along with this, it is absolutely neces- 
sary that the bowels should not become constipated ; conse- 
quently they should be opened with some pleasant purga- 
tive. I believe that an aperient is best under these circum- 
stances. Therefore a Seidlitz powder, or a small dose of Ep- 
som salts, or a glass of Apollinaris water, taken before break- 
fast, will accomplish the desired result. These not only aid 
in a general way in keeping the bowels open, but also have 
a palliative effect. But, besides their administration, that 
which I rely on most to quiet this local trouble is an injection 
of cold water, taken once or twice a day during the time that 
the trouble exists. This answers a twofold purpose : First, 
it washes out the rectum and prevents any lodgment of faecal 
matter ; and, second, the cold water coming in contact with 
the mucous membrane and the blood-vessels of the rectum 
proper prevents, in a certain degree, the inflammatory condi- 
tion. Therefore, when a patient consults me for external 



106 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

piles, the best advice that I can give is to sponge the part 
often with hot or cold water; to take an injection once or 
twice a day of cold, not hot, water ; and to assume the recum- 
bent position. It has become so common, however, to pre- 
scribe some ointment or other local application for external 
piles, that the patient expects it, and we are really compelled 
to follow along in this line of treatment. I have already said 
that I do not believe much in them. When we remember 
that an external pile is either a hypertrophied piece of skin, 
or a venous clot under the skin, we can understand that any 
ointment applied can accomplish very little good, unless it is 
absorbed, and the skin which covers both these varieties of 
piles has very little absorbing power, especially for grease. 
If it is thought best to prescribe a local treatment outside of 
what I have named, I would suggest the following: If the 
tumors are much enlarged and inflamed, make the patient go 
to bed and apply a large, hot flaxseed poultice. Now, in 
this case, as in all inflamed surfaces, it should be remembered 
that a small poultice or a cold one accomplishes nothing ; 
therefore the nurse should be instructed to make a very large 
poultice and to apply it while it is very hot to the inflamed 
haemorrhoids. As soon as it is cool, another one should be 
applied. This does more not only to palliate the distress, but 
also to eradicate the trouble, than any ointment. After the 
acute trouble has subsided, the parts are more or less in a re- 
laxed condition, and it is very well to prescribe an astringent 
solution. The following is a favorite of mine : 

1$ Act. plumbi 3 ij ; 

Ext. opium 3 j ; 

Aquae 5 viij. M. 

A cloth or a piece of surgeon's cotton, wet with this solu- 
tion, should be applied frequently to the part. As the 
trouble begins to disappear, an ointment is of more service, 
not from any anodyne effect, but rather from its constringing 
quality. Therefore I would suggest — 

^ Oxide of zinc ointment § j ; 

Hydgr. chl. mit 3 j. M. 



HEMORRHOIDS. 107 

This should be applied often and freely over the surfaces. 
I know that it is recommended to use the muriate of cocaine 
in these ointments for local application to external haemor- 
rhoids, but I have never seen that the agent was sufficiently 
absorbed to do any good in the way of quieting pain, and, be- 
sides this, it is very expensive, and the patients frequently 
complain of the cost. 

As a local application, hamamelis has been highly recom- 
mended, and I believe it to be of excellent service. In many 
affections witch-hazel has acted admirably in my hands, and 
as a local application in irritable and inflamed piles situ- 
ated at the margin of the anus, where the remedy could be 
easily applied, will be found to have but few equals. The 
part can be bathed in a solution three or four times a day, 
and a piece of lint dipped in it applied to the anus during the 
intervals. It makes a most excellent dressing. A person 
who has had one attack of external haemorrhoids is very 
liable to have another ; therefore it is best to offer some advice 
which may go to prevent the affection. I know of nothing 
better than the ordinary rules of health. He should eat, not 
sparingly, but of the proper things ; for instance, fish, rare 
beefsteak, well-cooked vegetables, and especially fruit. He 
should avoid whisky, beer, and ale. If he is an excessive 
smoker, he should become a moderate smoker, or no smoker 
at all. He should take a moderate degree of exercise during 
the day. He should sleep on a mattress, and not on a feather 
bed. If Nature does not move the bowels regularly, he should 
aid it by some aperient. Almost any of the mineral waters 
that are sold on draught at the drug stores in every city can be 
taken freely. In this section of country, what is known as 
Blue Lick water, and water from the French Lick Springs or 
West Baden Springs, in Indiana, meet the indication admir- 
ably. Indeed, I have thought that my patients who suffered 
with a disposition or a predisposition to haemorrhoids, who 
sojourned for a few weeks at either one of these springs dur- 
ing the summer, were much benefited in this respect. But 
these patients should be instructed that any irritant to the 



108 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

parts, such as printed paper as a detergent, should be avoided ; 
and, above all, that a cold ablution of the parts should be 
made after every act of defecation. This, together with a 
cold-water injection once or twice a week into the bowels, will 
go far toward preventing external haemorrhoids. 



CHAPTER VI. 

INTERNAL HAEMORRHOIDS. 

Internal haemorrhoids are of a much more serious na- 
ture, in so far as the health of the patient is concerned, than 
external haemorrhoids, and yet, if two patients were to come 
to the surgeon, one suffering from an ordinary attack of ex- 
ternal piles, the other with an uncomplicated case of internal 
piles, the former would give a history of a more serious 
trouble, at least to him, than the latter would concerning his 
case ; for pain is the predominant symptom in external piles, 
and pain is scarcely a symptom at all in uncomplicated inter- 
nal piles, and it is this one symptom that usually causes the 
patient to consult a surgeon for a haemorrhoidal disease. 
Hence we will see the one suffering from external piles early 
in the attack ; but a person will suffer the inconvenience of in- 
ternal haemorrhoids, such as protrusion at stool, or perhaps 
the staining of the linen during the day, etc., for a long time, 
and will not consult a physician, and it is only when some 
complication arises— such as ulceration or haemorrhage, or an 
inability to return the piles — that he seeks medical advice. 
We have said that internal haemorrhoids are the result of a 
disease of the coats of the blood-vessels which terminate in 
and beneath the mucous membrane. Now, this venous plexus 
is situated just within the anus and not as high as either one 
of the sphincter muscles. There is an opinion, even with 
physicians, that internal haemorrhoids are found very high 
up the bowel. Very of ten I have had them ask me if they 
were within reach, and if I could secure them without any 
trouble, when the truth is that haemorrhoids proper are never 
found high up the bowel. This plexus, which becomes dis- 



110 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

turbed in the h hemorrhoidal disease, lies just above the junc- 
tion of the mucous membrane with the skin, and when this 
congestion of the vessels terminates in the inflammatory 
state, which causes internal haemorrhoids by plastic exuda- 
tion, the tumors will be found just within the verge of the 
anus, and are easy to prolapse. Every surgeon knows that 
one patient coming to him with internal haemorrhoids will 
say that they protrude but slightly at stool ; another will say 
that the protrusion is very great ; and yet, when we come to. 
examine the two, we will find that the starting point is the 
same — namely, in the terminal venous plexus. One protrudes 
slightly, because the inflammatory action is not well estab- 
lished ; in other words, there are no well-defined tumors. 
The blood-vessels are congested and in a varicose condition ; 
not really, in my opinion, in the hemorrhoidal state, for I 
believe haemorrhoids to be tumors, and not varicosities. Now, 
where hemorrhoidal tumors have existed for a long time, the 
dilatation of the blood-vessels may extend rather high up the 
bowel, and can be easily seen on the mucous membrane, but 
this dilatation, or varicose condition, if you please, can not be 
called hemorrhoidal. ISTot until a hypertrophy of tissue, 
etc., take place can it be called a tumor. When the plexus 
beneath the mucous membrane within the external sphincter 
is thus affected, the haemorrhoids are said to be internal. 
When the veins beneath the integument outside the muscle 
enlarge, the haemorrhoids are said to be external. Because 
of the contiguity here of the blood-vessels we often have a 
mixed variety, partly external, partly internal. It is said by 
some authors that there are three well-marked varieties of 
internal piles — viz. : the capillary, the venous, and the arterial. 
I think this division is not only anatomically incorrect, but 
also misleading. The so-called capillary haemorrhoid is said 
to consist of a vascular area of small vessels, situated super- 
ficially in the mucous coat, and the venous haemorrhoid is 
said to consist of a varicosity of several large veins in the sub- 
mucous tissue, forming considerable tumors covered by mu- 
cous membrane. I have never been able to recognize any dis- 



INTERNAL HEMORRHOIDS. HI 

tinction, in an anatomical way, between these two. I am satis- 
fied that both the superficial and the deeper veins are impli- 
cated in the trouble ; or, in other words, I believe that these 
forms are but different stages of the same disease. Again, to 
the student, the term capillary, meaning a smaller variety of 
pile, is of the least importance ; and to him it is really insig- 
nificant in its nature, when, in truth, it is the most dangerous 
of either one of the varieties of internal haemorrhoids. It is 
from this small growth that excessive and dangerous haemor- 
rhage can, and often does occur. It has been my fortune to 
rescue several lives by recognizing in time a small capillary 
pile as being the point from which a dangerous haemorrhage 
was taking place. Later on I shall narrate a few cases illus- 
trative of this fact. The arterial variety, as described by 
some authors, consists in tumors in which are found numer- 
ous arteries and veins freely anastomosing, tortuous, and 
sometimes dilated into pouches. They are described as vary- 
ing in size, sessile or somewhat pedunculated, attaining some- 
times very considerable dimensions, glistening or slightly vil- 
lous on their surface, slippery to the touch, hard and vascu- 
lar, with an artery often as large as the radial entering their 
upper part. It is also said that they bleed freely when their 
surface is touched. Now, I must confess that I have never 
been able to make out these special characteristics of either 
one of the varieties of internal piles. From the description 
given of large venous haemorrhoids, one would suppose that 
they were easily recognized, but they are not ; having occa- 
sionally met with them, I have felt at their upper surface this 
artery, which is said to belong to this special variety, just as 
plainly in the venous variety, and I have never seen that they 
were any more disposed to bleed when touched than either 
one of the other varieties. But, on the contrary, when I have 
detected a pile that was glistening, slippery to the touch, and 
hard to the feel, it had very little disposition to bleed ; but it 
is the spongy pile, which is soft under the finger and easily 
compressed, which can by friction, such as is excited by hard 
faeces, etc., be easily torn and bleeds. I think it of more im- 



112 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

portance to call the attention of the student especially to that 
variety of hemorrhoid which is dangerous in itself, and from 
which can occur, at any time and from the slightest cause, a 
dangerous haemorrhage ; and that is the small, florid, rasp- 
berry-looking tumor, which may not amount to any more 
than a granular or a little spongy surface upon the mucous 
membrane. Indeed, when we recall the pathology of haemor- 
rhoids, we can scarcely call these haemorrhoids at all. There 
is no special cell growth, and but little connective tissue in 
their formation. They are situated higher up than haemor- 
rhoids are usually found, imbedded in or making a part of 
the varicose vein, and frequently implicate an arterial branch. 
So insignificant has this little spongy growth been in several 
dangerous cases of haemorrhage to which I have been called, 
that on opening the rectum with a speculum it could scarcely 
be seen, and had it not been that an oozing or spurting of 
blood was detected from the spot, it would have escaped no- 
tice. These certainly are not haemorrhoids proper. It may 
be a capillary condition, but that which I wish to impress 
upon the reader is, not to be misled by the classification usu- 
ally given of haemorrhoids. I have never yet recognized the 
so-called white piles, as described by Prof. Richet, of Paris. 
He states that they are merely ordinary piles in a more ad- 
vanced stage, and consist principally of hypertrophy of the 
capillary bodies of the mucous membrane. In several in- 
stances I have seen haemorrhoids look more or less white from 
excessive blanching due to an enormous loss of blood ; but 
this was simply one of the varieties which had been depleted 
of its blood supply. Others describe ncevoid piles, which are 
said to very closely resemble capillary ncevus. I think that 
this is simply a synonym for the capillary pile already de- 
scribed. Hamilton, of Dublin, suggests the term columnar 
pile to denote, as he suggests, its pathology, which consists 
essentially of hypertrophy of the folds of the mucous mem- 
brane surrounding the anal opening and pillars of Glisson. 
I believe this form of haemorrhoid is simply of the arterial 
variety. It would certainly simplify matters exceedingly if 



INTERNAL HEMORRHOIDS. 113 

we would lessen this division of haemorrhoids. First, let us 
say that there is one grand division — viz., external haemor- 
rhoids and internal haemorrhoids ; and that internal haemor- 
rhoids may be either large or small ; that when large, they 
protrude at stool ; that when small, they are not apt to pro- 
trude at all ; that the most dangerous form of internal piles is 
the small variety, from the fact that they are just beginning 
their formation. The blood-vessels distending and the mu- 
cous membrane being thin, rupture can easily take place and 
haemorrhage result. The large variety is not so disposed to 
bleed, owing to the fact that there is new-formed tissue and 
that the mucous membrane is thickened. The smaller variety 
is the most dangerous on this account, but the larger vari- 
ety is more troublesome outside of haemorrhage, simply be- 
cause the piles protrude. They are liable to complications, 
in that they can become irritated and inflamed and ulcerated. 
Now, it makes very little difference to the surgeon who is pre- 
pared to operate upon a case of internal piles whether they 
be capillary, venous, arterial, columnar, naevoid, or what not. 
He is going to operate just in the same manner without making 
any distinction, unless it be, as I have suggested, that in this 
little spongy outgrowth upon the mucous membrane, ordi- 
narily called capillary, he may apply a caustic to stop the 
bleeding and do no operation at all, or it may be that he pre- 
fers to catch up this little mass, and, by throwing a silk liga- 
ture around it, stop the haemorrhage. And right here it 
might be well to consider a subject that has received some 
attention— i. e., the source of the bleeding. I can not believe 
with Cripps that it is caused by its being forced as a regurgi- 
tant stream through a small rupture in a vein by the power- 
ful pressure of the abdominal muscles ; but I believe, and am 
satisfied in the belief, that the blood comes from the break- 
ing of some arterial branch. I have seen this jet occur so dis- 
tinctly and so clearly, without any reference to the action of 
the abdominal muscles, that I was satisfied that it was an ar- 
terial stream. Again, the nature and color of the blood evi- 
denced this fact. 



114 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

Case I. — I was called by a physician to see a lady patient 
who was suffering from an alarming haemorrhage from the 
rectum. She gave no history of rectal disease, but stated 
that all at once during that afternoon she felt a great desire 
to go to stool. She recognized that she was passing a large 
amount, she thought, of a liquid action. In an attempt to 
rise, she fainted, and it was revealed that she had passed 
nearly a chamberful of pure blood. The family physician 
was sent for, and after his arrival another severe haemorrhage 
took place. He immediately summoned me. The haemor- 
rhage was so excessive and the patient in such danger of 
losing her life that we had no time to search for any bleed- 
ing spot, especially as it was night ; so we determined at 
once to tampon the rectum, after which no further bleeding 
occurred. I am satisfied that this case was caused by the 
sudden rupture of an artery, perhaps in a so-called capillary 
pile, and that death would have ensued very soon but for the 
opportune use of the tampon. 

Case II.— On April 24, 1891, I was asked by my friend 
Dr. Allen to go with him to see a lady who was having some 
rectal haemorrhage. He did not put much stress upon it, 
however, so I did not take my instruments with me. When 
we reached the house the patient came into the parlor, ac- 
companied by her mother, who gave her some assistance. 
She was very pale and weak. She told me that for a num- 
ber of days she had been passing blood at stool, but thought 
nothing of it. She could give me no idea as to the quan- 
tity, but from her appearance I concluded that it must 
have been more than she estimated, or that she had malig- 
nant disease. She grew faint while talking to me, and I 
asked her to recline on a sofa in the room. I anointed my 
finger and introduced it into the rectum. The irritation 
caused by the finger created a desire to pass the contents of 
the bowel, and before she could rise she evacuated at least 
a quart of clotted blood. From this loss she fainted. Re- 
storatives were used, but her pulse remained very feeble, her 
limbs grew cold, she vomited, and a cold sweat was on the 



INTERNAL HEMORRHOIDS. 115 

surface of the body. I dispatched the doctor for instru- 
ments, etc., and upon his return I again inserted my finger 
with the same result as before, except that fully half a gal- 
lon passed at this time. The rectum was hurriedly washed 
out with boiling-hot water, and, after I had explained to 
her the fact that she was in a dangerous condition and must 
submit to what I was going to do to save her life, I pro- 
ceeded to tampon. Her condition was such as to contra-in- 
dicate the use of an anaesthetic. Having placed the tampon 
firmly in the rectum, I prepared to leave her in charge of her 
physician. When I left she was cold and nearly pulseless, 
she could not speak above a whisper, and said she was dying, 
which statement I believed. I was forced to leave the city 
the next day to attend the American Medical Association at 
Washington, and was gone a week. Upon my return, what 
was my surprise to hear from her physician that she was 
making a good recovery. I saw her about one month there- 
after, and she had regained her flesh and color and said she 
had never lost a drop of blood since the day that I tam- 
poned her. 

I am sure that the abdominal muscles did not aid in this 
spurting or jet of blood which caused this woman nearly to 
lose her life, but, from the history of the case, as in that of 
Case I, I am certain that it was due to the rupture of a 
twig of an artery. 

Case III. — Dr. I., of this city, a man of apparently good 
health and strong, robust constitution, had noticed for sev- 
eral weeks that he was growing very anaemic and weak. He 
could not account for the cause. His habit was to have his 
bowels move each day at his office in a dark water-closet, 
where the actions could not be seen. When he consulted 
me his complexion and general color indicated a man suffer- 
ing from cancer. He was scarcely able to walk up the steps 
to my office. He had lost his appetite, had no energy, was 
dizzy, and had fainted several times. He would go to stool 
a number of times through the day, would have what he 
would call a liquid evacuation, and supposed that he was 



116 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

suffering from diarrhoea. I suggested to him that perhaps 
he was losing blood at stool. He said that for some time he 
had had small haemorrhoids, which protruded somewhat at 
stool, and that they occasionally bled, which fact was evi- 
denced upon the paper which he used as a detergent. I 
made him lie upon my table, and an examination revealed 
the fact that there was a jet of blood to be easily seen when 
the sphincter muscle was open. Of course this cleared up 
the case. I had him go home. That afternoon I visited him 
and tied a small growth in which was this bleeding vessel. 
No further haemorrhage occurred, and he slowly but surely 
recovered his accustomed health and vigor. 

I cite these cases to show, first, the danger that attends 
the capillary variety of internal haemorrhoids, and, secondly, 
to describe them as accurately as I can, so as to prove that 
the blood comes from an artery, and not from a vein. I shall 
take occasion further on to speak again of haemorrhage from 
the rectum, and how to stop it. 

Outside of these extreme cases of haemorrhage from in- 
ternal piles we frequently meet patients who complain of 
a small loss of blood, perhaps each day. Some of them are 
disturbed from the fact that the linen is soiled, or they are 
made uncomfortable by their condition. Others often ask us 
the question, " Is this bleeding from haemorrhoids salu- 
tary ? ' ' and their question is frequently backed by the state- 
ment of the family physician, who has advised them to let it 
alone, giving as a reason that it is salutary, or that it will 
not do to stop the bleeding. Such a course of reasoning is, 
to my mind, fallacious. There may be some exceptions to 
the rule, but they are certainly very few. Such statements 
carry us back to the ancient writers, who considered the 
hemorrhoidal flux as an emunctory by means of which bile 
and other acrimonious humors were excreted from the turgid 
extremities of hemorrhoidal veins. Now, if to-day, under 
our enlightened physiology and pathology, we believe that 
" bile and other acrimonious humors" can be excreted 
through haemorrhoids, then, perforce of reason, we must ad- 



INTERNAL HEMORRHOIDS. 117 

mit that the bleeding from them is salutary. Hippocrates 
taught that haemorrhoids evacuated the " black bile of mel- 
ancholy humor. " If this statement be true, it would be quite 
a good idea to have some of our patients afflicted with bleed- 
ing haemorrhoids. But to-day we must recognize the fact 
that haemorrhoids are pathological, and not physiological. 
It has been said by some able writers that if the haemor- 
rhoidal flux be stopped, especially when it is habitual, it 
will produce general disorders. Some have gone so far as 
to compare this flux to the menses in women, the latter con- 
dition being purely a physiological one. 

Taking the view from any standpoint, I think it a very 
erroneous one, and one apt to do much harm, if the doctrine 
is promulgated. To lose blood from any condition, except 
it be a physiological one, must of necessity entail upon the 
patient at least a low vitality. No doubt, where a small 
amount of blood is lost from one of a full and plethoric habit, 
no special harm is noticed, but this is no good reason why a 
person of even that habit should lose the blood. Some have 
argued that where there has been a constant loss for some 
time — or, in other words, where it has become habitual — it 
would be deleterious to stop the flow, simply because it had 
become a habit. There can be no reason in any such logic. 
You might just as well say that a man who is habituated to 
the loss of some blood from the lungs every day should not 
have it stopped, for the reason that it would do him harm. 
I am not prepared to deny that in some subjects, especially 
drinking men of full habit, where the portal circulation is 
much engorged, the loss of some blood through the haemor- 
rhoidal tumors may be of benefit. These are exceptional 
cases, and we are too apt to make an exception a general 
rule. However, the subject is of sufficient importance to de- 
serve serious consideration. Things that have been handed 
down to us from antiquity we frequently have a great rever- 
ence for, perhaps because of their age or because our fore- 
fathers believed in them ; and I am inclined to believe that 
this doctrine . that haemorrhoids are salutary has come down 



118 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

to us in that good old way. It was taught and believed by 
the old-time physician that this bleeding not only proved of 
service in a special way, but also prevented many diseases in 
a general way. Even Galen said that haemorrhoids often 
prevented a commencing atrabilis, or cured it when it was 
established ; and that induration of the spleen, varices, gouty 
affections, and articular pain were also eradicated in this 
way. He also asserted that those who were the subjects of 
haemorrhoids were much less subject to other diseases. In- 
deed, you will find this belief so common with most persons 
that our patients will frequently object to having the haem- 
orrhage stopped. In this day, when medicine and surgery 
are based on and practiced from a scientific standpoint, 
we argue that haemorrhoids are a disease, and have in this 
chapter tried to give the pathology. A consideration simply 
of the causes of the existence of haemorrhoids should be suf- 
ficient to settle all questions as to whether they are a patho- 
logical or a physiological condition. But the great danger 
in teaching any such thing as this is that by the general ac- 
ceptance of such belief all classes are brought under its evil 
influence ; for instance, the anaemic woman, the debilitated 
man, children, etc., that can not bear up under the loss of 
blood, are instructed to believe that it is salutary, and jeop- 
ardize their lives. Of course no man learned in medicine 
would teach his clientele that such was the truth, but one 
has to practice medicine but a short while to know what a 
firm hold even superstitious ideas have upon the masses. 

Complications.— From the very nature of things, internal 
haemorrhoids are frequently complicated with other diseases ; 
indeed, other diseases are frequently the cause of internal 
haemorrhoids. As common among these we might mention 
an enlarged or displaced womb, the pregnant womb, tumors 
in the abdominal cavity, the diseased and hypertrophied 
prostate, stricture in the urethra, affections of the bladder, 
etc. All are common causes of internal haemorrhoids. So 
well recognized is this fact that authors frequently say that, 
unless the other diseases are rectified first, the treatment for 



INTERNAL HEMORRHOIDS. 119 

haemorrhoids will avail nothing. I am not willing to ad- 
mit this premise, for in many, if not in the majority, of in- 
stances where there is a complication the hemorrhoidal 
trouble is of the most importance. Allingham says: " In 
women suffering with a retroverted or anteverted uterus an 
operation upon piles is very undesirable and will most cer- 
tainly end in disappointment, unless the uterine complication 
be attended to at the same time, or, what is better, prior to 
the operation." 

Now, as I have hinted in a former chapter, of all patho- 
logical conditions that are difficult to cure, retroverted and 
anteverted wombs stand high in the list. Of their frequent 
occurrence I need not speak. If women suffering from one or 
the other of these conditions consult us for internal haemor- 
rhoids, which are a source of danger from bleeding, or of in- 
convenience from protruding, or painful from ulceration, we 
do an injustice to the woman not to relieve her of that trouble 
which gives her the most distress. Even admitting that the 
cause for her haemorrhoids was the retroverted or anteverted 
uterus, and that if the cause was not removed the haemor- 
rhoids would return, we would argue that for a time at least, 
and for a very long time perhaps, we should give her a sur- 
cease from her hemorrhoidal affliction ; and if by that time 
the womb had not been brought into proper place, and the 
haemorrhoids should reappear, to operate the second time 
would do her no serious harm. Therefore I must differ from 
the distinguished author, and say that my experience war- 
rants me in operating upon the haemorrhoids first, and refer- 
ring her to the gynaecologist afterward. Allingham states 
further on that he has found that the wounds do not com- 
monly heal, and that a very painful and unhealthy ulceration 
sometimes follows the operation ; and even if the wounds did 
heal, there was but little relief afforded. This has certainly 
not been my experience. I admit that in some cases the 
woman has said that she still had the bearing-down sensa- 
tion that existed before the operation was done to remove her 
piles, but we must remember that that was not all of her 



120 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

trouble. If the haemorrhoids protruded before the operation, 
they did not protrude after it. If they were ulcerated, the 
ulcerated tumor was removed. If pain was excited at defeca- 
tion, the pain has been stopped. I do not remember to have 
ever seen an ulceration established that would not heal after 
the operation under circumstances like these. To show the 
good effect to be had in these cases, I will make it suffice 
to cite only one case, but it is a sample of many in my 
practice : 

Case. — Mrs. Gr., living eight miles from the city, was a 
great sufferer from protruding internal haemorrhoids. Upon 
one occasion they became very much enlarged by inflamma- 
tion, protruded from the bowel, and the patient was unable 
to return them. She was in such dreadful pain that her 
family physician sent to this city for my friend, Dr. Frank 
C. Wilson, as a consultant. Upon arriving at the house, Dr. 
Wilson found this angry mass protruding, greatly inflamed 
and ulcerated. He suggested to the physician that an anaes- 
thetic be given, and the mass be returned within the bowel. 
This was done, but Dr. Wilson informed me that he had not 
got further than the gate when a messenger told him that 
the haemorrhoids had come out again. She was then advised 
to come to the city and have me operate. This she did. Upon 
my first visit to her I questioned her closely about her general 
health and any special complication that might exist along 
with the haemorrhoids. She told me that she had womb dis- 
ease, which included a displacement ; that she had been under 
treatment for it, and that just so soon as she recovered from 
this operation she expected to go under the treatment of Dr. 
Scott for the trouble. On the second visit I did the operation, 
Dr. Scott accompanying me and administering the anaesthetic. 
He corroborated what the woman had said. As she recovered 
from the operation for haemorrhoids she grew to feel so ex- 
ceedingly well that she deferred the treatment for her womb, 
and has expressed herself ever since as feeling like a new 
woman. 

I believe that this case speaks for itself. Here was a 



INTERNAL HEMORRHOIDS. 121 

woman incapacitated for either work or pleasure, with a co- 
existing uterine disease and a serious hemorrhoidal trouble. 
Although we recognized the womb complication, we did the 
operation for haemorrhoids first, and relieved her of the pro- 
trusion, of the inconvenience, and of the pain. Perhaps she 
has to-day the bearing-down sensation caused by a displaced 
womb. Suppose we had known at the time that she would 
have it, was that any reason why the operation should not 
have been performed ? 

I believe that where we have a complication of haemor- 
rhoids with urethral stricture it is of more importance to re- 
lieve the stricture than to relieve the displaced womb in the 
woman. It has been my misfortune in dealing with a great 
many to find that this form of trouble was a very serious 
complication of haemorrhoids. Another serious condition of 
affairs is the enlarged prostate in men suffering from internal 
haemorrhoids. That straining effort that the prostate pro- 
duces or superinduces has a baneful effect upon the hsemor- 
rhoidal affection. This, of course, is more likely to occur in 
old men, as the hypertrophied prostate is the bane of old age. 
And yet a radical relief can be afforded these people some- 
times by relieving them of their hemorrhoidal trouble. 

Case. — Mr. H. B., aged seventy-three, living in a small 
town in the interior of the State, had suffered for a long time 
from the effects of an enlarged prostate. In conjunction with 
this he had three or four well-developed internal haemorrhoids, 
which frequently became inflamed. Upon one occasion, when 
he was suffering both with his prostate and inflamed piles, 
and was unable to have his bladder act, his physician tele- 
graphed for me. I went out ; I found him to be rather a 
robust man for his age. Upon examination, the prostate 
proved to be very much hypertrophied. His piles were par- 
tially protruding and very sensitive. The urine had to be 
drawn every hour or two with a catheter. I argued that these 
haemorrhoids, which were frequently in a state of inflamma- 
tion, kept up this irritation of the prostate, and I advised an 
operation for their removal, This was done, and some weeks 



122 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

thereafter his doctor wrote me that he was in a much better 
condition, and expressed himself as greatly relieved. 

Of course, internal haemorrhoids can be complicated with 
other diseases of the rectum proper, such as an irritable ulcer, 
fissure, polypus, etc. When an operation is done for piles, 
the other should be attended to, if possible, at the same time. 
Internal haemorrhoids frequently become strangulated, and 
gangrene takes place. This is usually on account of an irri- 
table sphincter, which may be rendered so by an abrasion, 
fissure, or something of the sort. It will be found that the 
patient has made many efforts to replace them but has failed. 
Under these circumstances they are exceedingly sensitive to 
the touch, and the patient resists any attempt at an examina- 
tion or to force them back. If, under these circumstances, 
they are not returned within the sphincter, gangrene may be 
the result. There are a few cases reported where a slough of 
the entire hemorrhoidal mass has taken place, and a spon- 
taneous cure has been produced. Of course, this is a danger- 
ous thing to occur, in that a fatal haemorrhage might be the 
result. In cases like these it is said that the treatment must 
be either temporary or radical. I must certainly dissent from 
any effort at an attempted palliation or temporary treatment 
under circumstances like these. In the first place, if the in- 
flamed hemorrhoidal mass which has been strangulated is 
returned within the sphincter muscle, it will not remain there. 
In the second place, if it has become gangrenous it is a dan- 
gerous thing to allow it to remain there, for septic infection 
might rapidly take place. The only question to be considered 
is whether we are justified in operating upon internal haemor- 
rhoids when they are inflamed. Now, even if we are to admit 
that, as a rule, it would be safer not to do so, these are cer- 
tainly exceptional cases and call for radical relief ; but being 
of the opinion, as I am, that the results are just as good in 
operating upon haemorrhoids in the inflamed state as when 
they are not inflamed, it is my practice to advise an operation. 
And where the piles have become strangulated and are dis- 
posed to mortify, no delay should occur. The operation 



INTERNAL HEMORRHOIDS. 123 

should be done at once. Think of the condition of affairs if 
this inflamed hemorrhoidal mass is pushed back within the 
rectum, even if it will remain there ; and what a difficult 
thing it would be to qniet down said inflammation, to say 
nothing of all the pain or distress that the patient suffers. 

Case I. — Mr. N., living in the western portion of the city, 
had his piles to protrude, and made a nnmber of efforts to 
rednce them, but could not. He concluded that they would 
reduce themselves after a while, and therefore contented him- 
self with remaining at home, resting in the recumbent po- 
sition most of the time. During the clay he would take a 
number of drinks of whisky ; I suppose the amount tended, 
more or less, to quiet his pain. After the lapse of a week I 
was sent for, and he stated that, although they had not been 
reduced at all, the pain was not so great as it was for the first 
few days. On making an examination, I found what I took 
to be the cause of the diminution of pain— namely, that fully 
one half of the mass was in a state of gangrene. I advised an 
immediate operation. The patient was put under chloroform, 
and I removed the entire mass. This man made a perfect and 
uninterrupted recovery. 

Case II.— A young man from the country came to this 
city for the purpose of selling his tobacco. He was in the 
habit of getting on periodical drunks. One afternoon he dis- 
appeared from the hotel and could not be found by his father, 
who was searching for him during the evening and that night. 
The next morning one of the servants at the hotel reported 
that a man was in the water-closet, he thought, in a dying 
condition. It was ascertained that it was this gentleman, who 
had come in during the night, had gone to the water-closet, and 
in the act of defecating the hemorrhoids had protruded. He, 
being dead drunk, sat there all night. I was sent for the next 
morning, and upon examining him I found a mass on the out- 
side of the sphincter as large as my fist. It was exquisitely 
painful, and he was in such a nervous condition from drink 
and pain that I thought he would be attacked with delirium 
tremens. I made no effort to reduce this mass, because I 



121 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

thought everything indicated an operation. An assistant was 
called, and I removed it. For seven or eight days he did 
exceedingly well, but about this time he complained to me of 
an inability to open his mouth wide, and also that he swallowed 
with difficulty. I immediately suspected that this man had 
tetanus. I placed him at once upon the bromide treatment, 
giving enormous doses until full bromism was reached. For 
a number of days the symptoms progressed until he could 
scarcely open his mouth at all. He also had pains in the 
muscles of the chest and back, and a disposition to decided 
opisthotonus. He was still held, however, under the bro- 
mide, alternating occasionally with hydrate of chloral. Dur- 
ing the time, Dr. D. W. Yandell was called in consultation, 
and concurred in the treatment, and it was kept up. I do 
not remember the amount of bromide of potassium that this 
man took daily, but it was enormous. After the tenth or 
eleventh day the symptoms began to disappear, and the man 
made a good recovery. 

I have no doubt that the tetanus supervened upon this 
man's debauch, and was caused by it. 

Symptoms. — Internal haemorrhoids that do not protrude 
and do not bleed have few, if any, positive symptoms. In- 
deed, it is very seldom that a physician is called upon to 
prescribe for internal hemorrhoidal trouble where one or the 
other of these symptoms does not exist. It is true that in 
the rectum this varicose condition of the veins may exist, 
which predisposes to haemorrhoids, and often gives some inti- 
mation, by reflex action at least, of such condition. But we 
are not apt to see them in this stage. As has been stated, 
patients call almost any affection of the rectum or anus piles, 
and therefore it is left to the physician, after all, to make a 
diagnosis. The first symptom of importance is Ticemorrhage, 
and we know that the smallest and most insignificant pile is 
often accompanied by this symptom ; and when we add that 
capillary piles seldom protrude, we are compelled to make 
an examination with the speculum to ascertain whence the 
blood comes. The next important symptom is protrusion at 



INTERNAL HEMORRHOIDS. 125 

stool. The patient will say that during the act of defecation 
he has noticed that his bowel comes down, but that upon 
assuming the erect position it goes back again. As time 
goes on, or if we see the patient at a later period of the 
hemorrhoidal trouble, he will say that the piles protrude 
at stool, and that, although formerly they went back of their 
own accord, now he is compelled to push them back after 
each act of defecation. Right here I wish again to call to 
mind that very many patients are in the habit of pushing 
into the bowel the superfluous amount of skin which is found 
on the outside of the anus, whether in an inflamed condition 
or not. This practice should be deprecated, for it is the cause 
of much trouble. Time and again I have had to repeat to 
patients the advice that they must not do this. While writ- 
ing this chapter I have under observation a young man upon 
whom I have operated for a severe ulceration at the margin 
of the anus, caused by his daily attempt to push back his 
haemorrhoids into the rectum ; and this was done by the ad- 
vice of his physician. He had in reality no internal haemor- 
rhoids at all, but there were on the outside two large tags of 
skin which, by his constant attempt to reduce, had not only 
become inflamed themselves, but also had ulcerated the out- 
let of the rectum. At the same time that I divulsed his 
sphincter I removed his external piles, and he is now nearly 
well. I have known aged persons to say that they have suf- 
fered with protruding piles nearly all their lives, and suffered 
nothing more than the inconvenience of putting them back. 
Now, one would think that this inconvenience would have 
been of sufficient importance to the patient to have had them 
removed, but usually they have refused to do so upon a false 
idea that the piles were salutary, or that it was dangerous 
to have them operated upon. By other persons, after the 
existence of protruding piles for comparatively a short time, 
excessive pain is experienced in replacing them, and they 
seek the advice of a physician. When patients come to me 
complaining of haemorrhoids, among the first questions that 
I ask are these: "Do your piles protrude at stool? Do you 



126 DISEASES OF THE EECTUM, ANUS, AND SIGMOID FLEXURE. 

suffer any pain ? " If they give a history of protrusion with- 
out pain, then we have a pretty clear idea of an uncom- 
plicated case of piles. If they complain of pain with the 
protrusion or after it, then we know that we have a compli- 
cated case of piles. Internal haemorrhoids per se do not 
cause pain upon protrusion. If pain exists, an abrasion, fis- 
sure, or ulceration coexists. Frequently the patient suffer- 
ing from internal haemorrhoids will tell you that he dis- 
charges a good deal of mucus ; sometimes this accompanies 
the natural evacuation, sometimes it passes alone. With a 
very neat person the staining of the linen will be of sufficient 
importance to make him consult you for relief. Patients 
suffering from this form of trouble will tell you that, al- 
though the bowels move freely, afterward they feel as if 
there were more of the faecal mass in the bowel that should 
be passed. No doubt this is caused by the haemorrhoids act- 
ing as a foreign body in the rectum. There is usually some 
sympathetic action with the bladder, and if much irritation 
of the haemorrhoids exists, they will tell you that micturition 
takes place oftener than is natural. The reflexes may induce 
such symptoms as pain in the back and down the thighs, and 
with sensitive natures there is more or less a disturbance of 
the whole nervous system. Many patients suffering from in- 
ternal haemorrhoids imagine that they have malignant dis- 
ease, and it is a very difficult matter to persuade them that 
they have not, unless an operation is done which results in 
their entire recovery. In old- standing cases of haemorrhoids, 
especially in the aged, there is a relaxed condition of the 
sphincter muscle, and a disposition of the haemorrhoids to re- 
main protruded. But it has been my observation that where 
persons have attained to old age and have suffered from pro- 
truding haemorrhoids for many years, there is an atrophy 
of the tumors, and they will tell you that, although they suf- 
fered during their past life with the trouble, that now it 
causes them very little inconvenience. 

Diagnosis. — An examination should be made of every pa- 
tient who comes to you complaining of rectal trouble, and I 



INTERNAL HEMORRHOIDS. 127 

wish to enforce the suggestion that nobody's diagnosis is to 
be taken, but that it should be made out after careful study 
and examination of the patient. The history that will be 
narrated will sometimes give us a very good idea in forming 
an opinion of the existence of internal haemorrhoids, but 
very often we can not rely upon what the patient says about 
it. It is a very common thing that they are impressed with 
the idea that growths on the outside of the rectum have 
come down and properly belong inside. Besides this, al- 
though they give a clear history of protrusion at stool, it may 
be a polypus that has protruded, and the patient is not sup- 
posed to know the difference. In one or two instances it has 
been my misfortune to have patients complain of protruding 
piles when that which protruded was a portion of a malig- 
nant growth. Again, it is very natural for a patient to sup- 
pose that a prolapse of the gut proper is a case of internal 
piles. So I repeat that an examination should be made in 
each and all of these cases. Haemorrhoids, being veritable 
tumors, can be seen, but in the quiescent state can not be felt 
when within the rectum ; therefore, in order to see them, we 
must practice one of two means which are at our disposal. 
First, we must have the patient take an enema, and when 
the water passes away, he is directed to strain down, and 
these tumors protrude and can then be seen. But too much 
reliance should not be placed upon this method. It is very 
much like the person's going to the dentist to have a tooth 
extracted ; when he arrives there all pain may have de- 
parted. Many of my patients tell me, after taking an enema 
and " straining down," if but very little of the growth pro- 
trudes, that it isn't half as large, or perhaps one third as 
large, as it is ordinarily. Indeed, I have known patients who 
suffered with a well-pronounced case of internal piles, after 
taking an enema, especially of tepid water, and making the 
effort I have named, to have no protrusion at all. I account 
for this by the fact that the water has washed away any dis- 
charge or accumulated faeces, and it had passed easily, and 
even the straining effort would not bring them out. So if we 



128 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 




relied upon this method exclusively, we should be unable to 
make a diagnosis. 

Second, the next best plan is to have the patient wash out 
his bowel before you see him. Then, xolacing him on the 
table in the Sims position, by the aid of a good natural light, 
or an artificial light, as has been described in 
the chapter on " examination of the rectum," we 
anoint a speculum (a tri-valve or a four-valve is 
the best), introduce it into the rectum, and grad- 
ually open it to its full extent. The piles will be 
seen falling in between the blades. A very good 
plan which answers well, especially in the case of 
women, is to put them in the position named, and 
anoint the finger and slip it into the rectum, which 
accustoms the sphincter to its presence. Then, by 
gradually drawing apart the anus and telling the 
patient to strain down, enough of the hemor- 
rhoidal tumor or tumors can be seen to make a 
The physician who relies upon 
forming a correct opinion as to the exist- 
ence of internal haemorrhoids by the touch 
inside the sphincter will be often msitaken. 
It is a matter of some concern what we use 
as a lubricant for our finger and instru- 
ments. Soap and water will do very well 
for the gynaecologist, but it answers a very 
poor service to the rectal surgeon. In the 
first place, it is a very bad lubricant at best, 
and, secondly, it stings from the effect upon 
the mucous membrane. Some of the very best lubricants are 
lard, or butter without salt, or vaseline ; all of these are 
preferable to any oil, because they are more tenacious. Sup- 
pose, then, that there is a protrusion in answer to the strain- 
ing-down effort of the patient. As I have said, this may 
be one of three things, ruling out external haemorrhoids, 
which I take it for granted can be easily diagnosticated : 
first, internal hemorrhoids ; second, prolapsus of the gut ; 



Collin 



diagnosis. 




Candle holder with re- 
flector. 






INTERNAL HEMORRHOIDS. 129 

third, polypi. If it be hemorrhoidal, they can be felt as 
well as seen. They can be circumscribed by the finger, and 
feel to be more or less solid as tumors. They can be de- 
fined and counted. If it be prolapsus, a protrusion is likely 
to exist all around the anus. It hasn't the appearance of 
internal haemorrhoids, in that it is of a brighter or scarlet 
color, whereas the haemorrhoids are of a dark, venous color. 
It does not evidence to the feel the same sensation as internal 
haemorrhoids. It is soft and velvety, giving the sensation of 
a' wet bladder pressed together with the fingers. If it be a 
polypus, although the protruding part may look very much 
like a pile, it will be found that it has a pedicle. Therefore, 
in my opinion, internal haemorrhoids can be easily diagnos- 
ticated. 

Treatment. — The treatment of internal haemorrhoids can 
best be considered under two heads : first, palliative treat- 
ment ; second, radical cure by operation. I sometimes think 
that authors make a mistake in devoting so much time to the 
palliative treatment of internal haemorrhoids. If this disease 
actually exists, palliative treatment will not cure it ; and to 
soothe the patient into the belief that he is being benefited or 
cured by such treatment is doing him an injustice. Where 
the haemorrhoidal disease exists, with the pathology as named 
in this chapter, I do not believe it can be cured in any other 
way than by operative proceedings. It is this very method 
that we are objecting to, either in the hands of the charlatan 
or by the dictation of druggists, or possibly of old women, 
who are in the habit of prescribing infallible cures for piles 
in the way of salves, ointments, lotions, etc. Indeed, the 
whole effort of the quack seems to be to persuade these peo- 
ple that they can be cured "without the use of the knife, 
clamp, ligature, or cautery. " From a surgical standpoint we 
know how erroneous this is, and yet there are persons that 
will submit to having a tumor — say of the breast — removed 
by daily application of a painful caustic, which it will take 
weeks or months to do, when a cure could be effected in one 
tenth of the time by a clean incision by the knife. So it is 



130 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

with these cases. The hemorrhoidal tumor can be removed 
by an operation in a few minutes, and the cure is a radical 
one ; and yet, by an education in a false theory, these patients 
undergo treatment from the itinerant for weeks, months, and 
perhaps years, without having the end accomplished. When 
we say palliative treatment for internal haemorrhoids, we mean 
palliative and not curative ; and, therefore, we should say to 
the patient: "I can palliate your disease by certain means, 
but I can not cure it." But recognizing the fact that there 
are many persons, especially business men and women, who 
perhaps can not spare the time to be operated on, we must 
give them some treatment. Therefore this will form my 
excuse for mentioning it. First of all, then, I would inquire 
into the patient's habits. If he is a drinking man, his allow- 
ance of alcohol must be cut off or limited, and if the effect of 
drink has shown itself upon the liver, it must be looked after. 
With his agreement to stop the stimulant, if not for all time, 
for a short time at least, I would have him drink freely of 
some one of the mineral waters. About the best is the Carls- 
bad. This should be taken first for its free purgative effect, 
and for its saline effect afterward. Then I am in the habit of 
prescribing for these men the following : 
Iji Tincture of cinchona, 

Tincture of gentian aa § iv ; 

Hydrarg. bichlor gr. ij. 

M. Sig. : Teaspoonful three times a day before eating. 
This preparation is not only a good tonic, but the mercury 
has a beneficial effect upon the liver. These people are usu- 
ally heavy eaters, and therefore they should be enjoined to 
restrict their diet to common nutritious food, eating often of 
fruit and taking their meals with regularity. I have known 
these patients to be greatly benefited by taking each night at 
bed-time a lemon squeezed into a glass of hot or cold water. 
The diet should be looked after with all classes of patients. 
Women, especially, are in the habit of eating sweetmeats to 
excess. These should be interdicted, and a good nourishing 
diet substituted. 



INTERNAL HEMORRHOIDS. 131 

In regard to this special injunction relating to diet, Brodie 
has given such admirable suggestions that I beg leave to 
quote him : u Is the patient a great eater, pampering his 
appetite with a great variety of dishes and thus exciting 
himself to swallow more food than the stomach can readily 
digest % Let him make his dinner on a single dish, and eat 
of that in moderate quantity. Let him avoid undressed vege- 
tables, especially those which are acid or acescent, as salads, 
oranges, and apples. Does he commit excesses in drinking % 
Let him leave off fermented liquors altogether, or take them 
only in small quantities ; and, in particular, let him avoid such 
fermented liquors as from the sugar which remains unfer- 
mented in them are liable to become acid in the stomach, or 
which are acid altogether. The French light wines are in- 
jurious in these cases, especially champagne. So are also 
all varieties of malt liquor, from Burton ale down to home- 
brewed beer ; but none of these liquors are worse than our 
old-fashioned English liquor called punch. If your patient 
has been in the habit of dining late in the evening, and of 
going to bed soon after a hearty meal, he should alter his 
habits in this respect, dining sufficiently early to allow his 
food to be digested before he retires to rest. If he has led a 
sedentary life, he should cease to do so, walking or riding 
daily, so as to induce perspiration. A person who takes a 
good deal of exercise may take liberties as to diet which he 
could not otherwise take with impunity." 

Outside of any benefit that might accrue to the patient 
suffering from haemorrhoids, these suggestions of Brodie con- 
stitute a splendid moral lesson that would be of service to all 
mankind if followed. I fear the American would be averse 
to such precautions, simply for their salutary effect. There 
is one article of diet which is commonly supposed to be of 
great benefit to persons suffering from any form of rectal 
trouble, from constipation to haemorrhoids. I refer to oat- 
meal. Many authorities impress upon us the necessity of 
such a diet in certain diseases of the intestines. My expe- 
rience with this article of food has been that it does more 



132 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 




harm than good. In the chapter on diseases of the sigmoid 
flexure I recite a case where death resulted from an impac- 
tion, or I should speak more correctly if I were to say by 
an agglutination, in the sigmoid flexure, caused by the too 
free use of oatmeal. We can not do better than tell the pa- 
tient to eat good, digestible, 
wholesome food, letting all 
pastry and other sweet- 
meats alone ; to observe 
regular habits as far as pos- 
sible ; to avoid constipa- 
tion ; to take a good deal 
of exercise in the open air 

Trousseau's pile supporter. 

— at least not to follow a 
sedentary life ; and to partake sparingly of the stimulants, 
especially alcohol. This is about all that they will do, and it 
will be a very difficult matter to get them to do even this. 

Local Applications. — Under the head of local applications 
many things could be mentioned, but 
very few of them do any good. I would 
advise the patient suffering from a dis- 
position to internal haemorrhoids to see 
to it that no constipation existed. To 
prevent this form of trouble I would re- Metal pile plug " 

fer my readers to the chapter on 
constipation. Outside of all gen- 
eral rules relating to that subject, 
and coming more directly to the 
preventive treatment of internal 
haemorrhoids — for that is a bet- 
ter term to use than palliative — I 
would advise the patient to wash 
the bowel out at least three times 
a week with a large cold-water in- 
Proiapsus ani supporter. jection, unless there was some spe- 

cial reason why it should not be done. In addition to this, I 
would urge him not to use any form of paper or other substance 





INTERNAL HEMORRHOIDS. 



133 




as a detergent, but, instead, to practice the use of a cold-water 
ablution of the parts after ea,ch act of defecation. I believe 
cold water applied to the inside of the rectum, and outside of 
it, to be the best agent either to prevent the hemorrhoidal 
disease or to palliate it when it exists. Its astringent effect 
upon the muscular structure of the bowel and blood-vessels 
can not be denied. It might 
be said that after the astrin- 
gent effect we would have a 
reaction and a greater dila- 
tation of the blood-vessels ; 
but this assertion might be 
made in regard to the appli- 
cation of cold to inflamed Pile supporter elastic ' 
surfaces generally, and yet we know of what service cold is in 
many ways in cases of inflammation. Van Buren believed that 
it was best to throw up three quarters of a pint of tepid water, 
with a view to bringing the motions away ; then, after the mo- 
tion, to inject four 
ounces of quite cold 
water, which can be 
either retained or 
passed out in a few 
minutes. I have had 
a better effect from 
throwing a larger 
quantity of water in, 
say from a pint to 
two pints of cold wa- 
ter at a time. This 
not only breaks 
down and washes 
out the fsecal mat- 
ter, but acts at the 




Pile supporter elastic. 



same time as an astringent to the parts. All instruments de- 
vised for the purpose of keeping the hemorrhoids up in the 
rectum, after they are reduced, have proved utterly worthless 



134 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

in my hands. The best, however, are the ones illustrated 
here. Cripps recommends, in such cases, a daily passage 
of a full-sized conical bougie up the bowel immediately after 
the motions, and that it should be kept in for a few min- 
utes. He does not state for what purpose this is done, but 
it occurs to me that this would be adding fuel to the flame. 
The sphincter muscle is likely already irritated, and even if 
it has not sufficient action, I can not understand how the 
introduction of the finger can establish it. We are often 
forced to prescribe some treatment for haemorrhoids that are 
prolapsed in an inflamed state. The usual method is to give 
a prescription of some form of opiate as an ointment, gener- 
ally of powdered opium and belladonna. A favorite pre- 
scription with Allingham is the following : 

$ Ext. belladonnse 3 j ; 

Ext. hyoscyami 3 ij ; 

Ext. conii 3 ij ; 

Yaseline § j. M. 

This is applied on a piece of lint or rubbed over the parts. 
A better formula, to my mind, is — 

5 Mur. cocaine gr. xij ; 

Iodoform 3 j ; 

Ext. opium 3 ss. ; 

Vaseline § j. M. 

These can be used through pile-pipe, if thought best, or 
applied locally. 

I must confess, however, that I have very little faith in 
such local applications either quieting the inflammation in 




Hard rubber pile-pipe. 



the hemorrhoidal tumor or quieting pain by being absorbed. 
I am satisfied that the absorbing power of an inflamed hsem- 
orrhoid is very feeble, to say the least of it. A better plan, I 



INTERNAL HEMORRHOIDS. 135 

think, as far as palliation goes, if the haemorrhoids are pro- 
truded and can not be returned, is to put a large hot flaxseed 
poultice over them and to have it frequently changed and the 
patient kept at perfect rest. If the haemorrhoids can be re- 
duced, then we get a quicker and more perfect effect by giv- 




Hutchinson's ointment syringe. 

ing a hypodermic injection of morphine. But, in lieu of all 
this, a much better plan of treatment for protruded inflamed 
piles is to suggest an immediate operation for their removal. 
I have practiced it many times, and I have never yet had to 
regret it. Indeed, I think it more necessary to operate upon 
inflamed internal piles than to operate upon those that are 
not inflamed. 

Operations for Internal Haemorrhoids. — After we have deter- 
mined to operate for internal haemorrhoids, it is best to give 
the patient a little preparatory treatment before the opera- 
tion. If I suspect, or am told, that the patient is a drinking 
man, I administer for a couple of nights a dose of calomel, 
say two or three grains each night, or, what is better, give 
this amount in reduced doses, say one fifth of a grain, taken 
every hour until three or four grains are taken. I then have 
the patient take a large dose of sulphate of magnesia the day 
before doing the operation. The night before, I have a large 
enema of hot water thrown into the rectum, to wash it out. 
Early the next morning I have it repeated. If the patient is 
to take an anaesthetic, of course he should do without the 
meal which precedes the operation. It is a bad habit to oper- 
ate upon patients who come from a distance on the day 
of their arrival. They are fatigued, perhaps, with the jour- 



136 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ney, and out of sorts in a general way ; besides this, you 
have not sufficient time to unload the bowels, as directed. 
Very many patients insist upon this early operation to save 
time, but the surgeon should consider not only his patient's 
welfare, but also his own reputation, in doing surgical opera- 
tions. We are to suppose, then, that the patient has been 
prepared for the operation, as suggested in the chapter on 
antiseptics in rectal surgery. Presuming that he has been 
given a bath, and that everything concerned in and about the 
operation is aseptic, we are to proceed. The favorite posi- 
tion with me is : the patient lying on his left side, at the edge 
of the operating-table, with the knees well drawn up, and his 
left arm drawn from under him. One assistant should stand 
at the patient's head in giving chloroform, and not at the 
side, for the reason that he is in the way. Another assistant 
should stand in front of the patient, to assist in controlling 
the parts. The nurse should be prepared to handle the in- 
struments, sponges, irrigator, etc. If a surgeon attempts to 
do an operation for internal haemorrhoids with no one present 
but the physician who gives the anaesthetic and himself, he 
will find that he will do an awkward operation. 

Methods. — There are thirteen recognized operations for in- 
ternal hsemorrhoids. Having very little confidence in some 
of them, I shall not take the time to speak of how they are 
done. Really, there are but two operations that claim much 
attention from surgeons who are in the habit of doing these 
operations : 1. The ligature. 2. The clamp and cautery. 

As I desire to pay my respects to a few other methods, I 
will consider the following operations that are practiced for 
internal hsemorrhoids : 1. Injections of carbolic acid. 2. 
Crushing. 3. Clamp and cautery. 4. Excision. 5. Dilatation 
of the sphincter muscles. 6. Whitehead's operation. 7. 
Ligature. 

Injections of Carbolic Acid. — As we are greatly indebted 
to Dr. Edmund Andrews for an expose of this method of 
treatment, which originated with the itinerants, I shall take 
the liberty of quoting him freely, and afterward of giving 



INTERNAL HEMORRHOIDS. 137 

my own opinion. In his work on Rectal and Anal Surgery 
published in 1888, he has this to say of the origin of this 
method of treatment : " In the year 1871 there lived in the 
village of Clinton, near Jacksonville, 111., a young physician 
named Mitchell. His practice was small, and afforded him 
superabundant leisure, which he employed in devising a new 
treatment for piles. Being a good thinker, he soon conceived 
the idea of treating haemorrhoids by the hypodermic injec- 
tion of a mixture of olive oil and carbolic acid. Having tried 
his plan upon an old farmer of the neighborhood, he accom- 
plished a triumphant cure. The old farmer w T as delighted 
and garrulous, and the young doctor was needy, but ambi- 
tious. The two made a sort of partnership, the old farmer 
attending to the advertising, while the young doctor received 
the patients and punctured their piles (and their pockets) 
with his little hypodermic syringe. Knowledge of their 
method spread. Certain itinerants began to sell the secret to 
others, pledging them to secrecy in turn, and binding each to 
practice only in the district for which he had purchased the 
'right.' Two men in Chicago are said to have paid three 
thousand dollars for the exclusive secret right to a certain 
portion of Illinois, including their city. Flocks of itinerants 
bought the secret and traversed the country in every direc- 
tion until their handbills fluttered on the shores of the Pacific 
Ocean. In the year 1876 one of the quacks revealed to us his 
method, and, by taking measures adapted to the purpose, we 
found that he had informed us correctly. We then entered 
into correspondence with a considerable number of the itin- 
erants, some of whom proved willing to make a clean breast. 
We also communicated with a large number of regular physi- 
cians who had observed the practice of the itinerants, and in 
some cases had made use of the method themselves. In the 
course of this investigation we received about three hundred 
letters, and got rough estimates of the results of the injec- 
tions in about 3,300 cases. Mitchell commenced with a mixt- 
ure of one part of carbolic acid and two parts of olive oil, 
but he gradually varied from his first method, and at length 



138 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

partly abandoned the injection and adopted the plan of tear- 
ing the interior of the piles to pieces by means of angular 
needles set in handles. He probably met with some of the 
dangerous accidents which have occurred in the injecting 
practice, and changed to the needles on that account." 

Dr. Andrews reports the following accidents which were 
reported to him out of 3,304 cases : Deaths, 13 ; embolism of 
liver, 8 ; sudden and dangerous prostration, 1 ; abscess of 
liver, 1 ; dangerous haemorrhage, 10 ; permanent impotence, 
1 ; stricture of the rectum, 2 ; violent pain, 83 ; carbolic-acid 
poisoning, 1 ; failure to cure, 19 ; severe inflammation, 10 ; 
sloughing and other accidents, 35. 

Now, when it is considered that this evidence is given by 
the itinerant himself, who would be disposed to report his 
successes, but not his failures, and again that these men 
know no surgery or pathology, this is very poor evidence 
indeed. Statistics are poor at best, but when gathered from 
such sources as these they amount to but little, so far as the 
danger of the treatment is concerned. But the profession is 
greatly indebted to Dr. Andrews for his exposure of these 
men and their plans. Shortly after this method of treatment 
became known to the profession I took occasion to use it in 
forty cases of internal haemorrhoids, and in an article read 
before the Kentucky State Medical Society, in 1878, I gave 
my experience with the agent. Allingham, in his work on 
Diseases of the Kectum, page 120, refers to my report in 
the following words: " Dr. Mathews, of Louisville, has 
kindly sent me his pamphlet, read before the Kentucky State 
Medical Society in 1878, and in that paper he endeavors to 
show that the injection of the acid into a pile is painful and 
inefficient, and that death is to be feared (a) from peritonitis, 
(b) from embolism, and (c) from pyaemia (sepsis). In support 
of his assertion, he relates a case under the care of another 
practitioner, where in twelve hours violent inflammation fol- 
lowed but the piles were not cured, for in twenty days after 
the injection one tumor had to be removed by ligature. He 
also cites another case of peritoneal inflammation, and says 



INTERNAL HEMORRHOIDS. I39 

embolism and pyaemia have been known to result from inject- 
ing naevi with solution of iron, and deaths have occurred 
from injecting internal haemorrhoids with carbolic acid. For 
my own part, I am much inclined to agree with the opinion 
of Dr. Mathews. I have tried the injecting plan in many 
cases, but the result was generally much pain, more inflam- 
mation than was desirable, a lengthy treatment, and the re- 
sult doubtful ; certainly not a radical cure, for it must be 
borne in mind that though the injection of carbolic acid into 
the interior of piles may, in some instances, stop the bleed- 
ing for a time, yet it can not, and does not in any way, re- 
move the tumors. It, consequently, does not prevent prolap- 
sus and the discomfort arising from that condition, which gen- 
erally causes more trouble to the patient than slight bleeding. 
It appears to me that all attempts to destroy vascular growths 
by causing coagulation of blood, or inflammation in them, 
while they are not shut off from the general circulation, must 
be fraught with danger. You can have no guarantee that the 
coagulum may not break down and minute particles of dead 
tissue find their way into the vascular or lymphatic system, 
and result in embolism or pyaemia, or both." 

This statement in regard to this treatment, coming from 
a surgeon who is recognized as a leading authority upon rec- 
tal diseases, should be received by the profession with the 
greatest respect. At the time I wrote my article condemning 
this method I was in correspondence with many of the lead- 
ing surgeons of this country and with several in Europe re- 
garding its use. 

The observations of learned authorities are to be regarded 
with more favor than evidence from other sources. I sub- 
mitted the question to Allingham, Gowland, Goodsall, 
and Cooper, of England, to Erskine Mason, Van Buren, and 
Bodenhamer, of this country, and to a number of others 
whose names I can not now remember. Mason said to me 
that he had not used the acid, because he did not consider it 
the proper thing to do. Van Buren wrote me that he would 
not use the agent for the reason that he considered it un- 



140 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

surgical, and likely to be attended with great danger. Gross 
said : "Of the various injections that have been used for the 
relief of these tumors, the principal are nitric acid, creasote, 
iodine, and perchloride of iron, introduced in small quanti- 
ties, either pure or diluted, with a delicate syringe. These 
fluids are all more or less irritating, while several of them are 
capable of exciting high inflammation ; hence it is hardly 
necessary to add that they should be employed with the 
greatest possible care and gentleness." The others discounte- 
nanced the plan. 

The conclusions that I published in 1878 I have no reason 
to change to-day, but, on the contrary, I wish to reaffirm 
them. I have long since abandoned the method in my own 
practice, and it is a common observation with me to see pa- 
tients who have been injured, and in some instances where 
life was endangered, by its use. 

I know of several deaths that have resulted from this in- 
jecting plan ; a number of instances where excessive and dan- 
gerous haemorrhage resulted ; a few where stricture of the 
rectum was caused by it ; a considerable number where ul- 
ceration of the gut took place ; two instances . where an im- 
mense internal fistula was established, etc. 

Case I.— Mr. B., aged about forty-five, a very healthy and 
robust man, was afflicted with an ordinary case of internal 
haemorrhoids. He consulted an itinerant who used the injec- 
tion of carbolic acid into the tumors. This man was confined 
to his bed for three months with a violent inflammation of 
the rectum, accompanied by abscesses, which resulted in a 
sloughing out not only of the tumor, but also of much of the 
tissue of the rectum. At this time I was called to see him. 
Upon introducing my finger into the rectum, I could easily 
push it into a large ragged opening that ran down into the 
tissues, beginning about one inch above the external sphinc- 
ter muscle. A great amount of pus flowed out of the rectum 
with this slight dilatation of the muscle. I informed him 
that an operation would be necessary to effect a cure. I also 
told him that I feared the sphincter muscle was undermined 



INTERNAL HEMORRHOIDS. 141 

and perhaps involved in this trouble, and that he might have 
some incontinence of fseces following the operation. He was 
willing to submit to any operation which promised relief. 
After some preparatory treatment, I operated on him in a few 
days by making a clear incision into the cavity, laying open 
the sinuses, scraping the bottom of the cavity, and trimming 
off the edges. By careful treatment afterward, the parts 
healed nicely and I discharged him cured. 

Case II. — Miss L., a young lady living in a Southern city, 
consulted an advertiser in regard to some rectal affection, 
and the carbolic-acid treatment was used in her case. As 
the result, violent inflammation ensued, an abscess formed 
inside of the rectum, which broke of its own accord, and was 
attended by a sloughing of tissues, very much like the first 
case. She came to me a few weeks afterward, and an exami- 
nation revealed the condition that I have described. In this 
case I also recommended and did an operation something like 
that in Case I, but not so extensive. Before I operated on 
her, this girl suffered the most intense agony every time the 
bowels moved, but there was more or less distressing pain all 
the time. After I operated, all pain disappeared, the wounds 
healed nicely, and she was discharged cured. 

Case III. — Mr. U., a worthy shoe merchant of this city, 
had been operated on for internal piles by an advertiser. He 
was assured that his cure was perfect and permanent. About 
two months after, in a slight straining at stool, he noticed the 
protrusion of a large mass, which was very like what he had 
before any operation was done. He consulted his family 
physician, and he, recognizing the condition of affairs, advised 
the patient to visit me. This he did, and I told him that 
these were haemorrhoids, but not of recent date. He replied 
that he had been assured of his perfect cure, a good fee had 
been collected, and his name was carried on the circular of 
the advertising physician as one of his references. I oper- 
ated upon this man, removing five large hsemorrhoidal tu- 
mors by the ligature. 

Case IV. — A railroad conductor consulted an advertiser 



142 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and had his piles injected. He was told that it need not 
interfere with his business, and that he could run his train 
that evening. Not knowing of any danger, he took this 
advice, and when about fifty miles from this city a violent 
haemorrhage from the rectum occurred. He was taken off 
the train, and for a time it was thought that he would die. 
A physician, however, succeeded in stopping the haemor- 
rhage, and advised him to rest for a considerable time, which 
he did ; and he eventually recovered. 

I have cited these four cases simply as samples of what 
I have observed to result from the use of the carbolic-acid 
treatment of internal haemorrhoids. I do not believe that 
it should be classed with the legitimate operations, and I 
would not now give it so much attention but for the fact 
that a number of good men in the profession have dis- 
cussed the subject, but only a few remain to advocate its 
use. In the July number of the American Journal of the 
Medical Sciences, 1885, Kelsey reported about two hundred 
cases treated by this plan. At that time he was inclined to 
look upon it with much favor, but in a later article he does 
not speak of it in a very favorable way, and, indeed, said to 
me a short while ago that he had about abandoned its use. 
Agnew, of San Francisco, in his work on Diagnosis and 
Treatment of Haemorrhoids, and other Rectal Diseases, freely 
advocates the carbolic-acid treatment. He says: " There are 
no tenable objections to the treatment of haemorrhoids by 
carbolic-acid injection, rationally and scientifically applied, 
which can not be equally urged against the more heroic plans 
of treatment advocated and generally adopted. But there 
are many serious and unavoidable drawbacks inherent in the 
latter methods of cure which are wholly and incon trover tibly 
absent in the former method." 

I think this is stating it too strongly. In the first place, 
it must be admitted that this method of treatment is nearly 
entirely confined to the itinerant, who is not able to apply it 
either " rationally or scientifically." I do not know either 
that the plans "usually practiced for the cure of haemor- 



INTERNAL HEMORRHOIDS. 1^3 

rhoids"are "heroic," and as to the statement that "there 
are many serious and unavoidable drawbacks " in such plans 
that do not obtain in the acid treatment, it can not be borne 
^out by facts. To inject an acid into a haemorrhoidal tumor, 
coagulating the blood in the same, when a good-sized artery 
is supplying the tumor, is certainly not as safe as to cut off 
the hemorrhoid from the general circulation by a silk liga- 
ture. Dr. W. T. Bull, the eminent surgeon, of New York, in 
speaking of this method in treating piles, says : " There have 
been reported instances of phlebitis, pyaemia, and death from 
its use ; hence the method is to be employed with caution. A 
number of relapses have occurred, and I am disposed, there- 
fore, to place the method among the palliative remedies." 

Therefore, to conclude : so far as this treatment of inter- 
nal haemorrhoids is concerned, I would say that I quite agree 
with the learned surgeons who oppose its use as a radical 
method of curing the disease. It is attended with much dan- 
ger, great pain, and certainly not with radical cures. There 
can be no special gauge as to the amount of the acid that 
should be thrown into a haemorrhoid to effect its removal, 
and it is natural for the sloughing process to take place, and 
in doing so too much tissue may be destroyed ; hence we 
may have internal fistulas originated in this way. In an 
effort at cicatrization, a stricture may result, and, as we have 
shown, violent haemorrhage often takes place. That my 
views were not chimerical in regard to the following of this 
treatment by embolism, and to the occurrence of death in 
consequence, I cite the report made by Andrews and others, 
which verifies my predictions. In my opinion, it is the least 
surgical of all known plans for the cure of internal haemor- 
rhoids. 

For those desiring to test the treatment, it would be best 
to use a solution of one part of pure carbolic acid, three of 
glycerin, and three of water. Kelsey says that he prefers the 
the carbolic acid reduced one half in the solution. In my ex- 
periments it occurred to me that those patients did best where 
the percentage of the acid was greatest, but, as I discounte- 



144 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



nanced the treatment as a radical operation, I agree with Bull 
that it should be regarded only as palliative, and the less the 
amount of acid used, the less is the danger to be apprehended, 
so far as a deep slough is concerned. I believe the amount in-, 

jected of the solution that 
1 have named should be 
ten or twelve drops, but 
Kelsey suggests jive drops 
into each tumor of a 
stronger solution. Haem- 
orrhoids can best be in- 
jected when they are pro- 
truded. The speculum is 
used by some, but, in my 
opinion, it does not com- 
pare with the other plan. 
The patient, by his own 
effort at straining, can usu- 
ally force the tumors out. 
If not, they can be drawn 
down with forceps. The 
injection should be thrown 
into the center of the tu- 
mor, or at least as near it as 
it is possible to do. After 
the haemorrhoids are inject- 
ed, they should be pushed 
back into into the rectum, 
and the patient should be 
commanded to remain in 
bed. It is suggested by 
Kelsey and others that only 
one tumor be injected at a 
time, and not to repeat the injection for one week. When I 
began experimenting with this plan I thought as they do ; 
but later on I became convinced that it was just as well to 
inject at least two tumors at the same time. Kelsey, in 




INTERNAL HEMORRHOIDS. 



145 



speaking of the subject, says: "But no such use of the 
acid is necessary to effect a cure, and sloughing is a result 
which I try very carefully to avoid." Of one thing I am posi- 
tively certain: that, unless sloughing of the tumor occurs, 
there is no radical cure, and if sloughing does not occur, the 
remedy must be regarded as palliative and not curative. 

Crushing. — After Mr. Pollock wrote his paper, which 
appeared in the Lancet in 1888, I was rather impressed with 
the idea of crushing as a means of curing internal haemor- 
rhoids, and the results that I obtained were very good ; but 
after antiseptic surgery came into use I was persuaded that 
there was more danger in leaving the crushed stump of a pile 
in the bowel than I had anticipated, and therefore, for theo- 
retical reasons, more than from any result that I had, I aban- 
doned the treatment. It is certain that we would run a risk 




Self-blowing alcohol lamp for heating cautery irons. 

of sepsis if we left the bowel as it would be left after the 
crushing method. Herbert Allingham has improved upon 
the method of Pollock, and approves crushing as a means 
of treating internal piles. 

Clamp and Cautery. — Whatever advantage the clamp and 
cautery can have as a method in treating internal haemor- 
rhoids, we are indebted to Mr. Henry Smith for it. As near as 
10 



146 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

an operation can be closely associated with one's name, this 
operation is allied to Mr. Smith's. Not that he devised it, 
for that credit must be given to Mr. Cusack, of Dublin. Nor 
did he first introduce it into London ; that was done by Mr. 
Henry Lee ; but Mr. Smith has been an ardent advocate of it, 
and has used it, perhaps more than any one living, in doing 
the operation for internal haemorrhoids. In this country it 
has been received with but little favor. Kelsey, however, is 




Paquelin's thermocautery. 

a firm believer in the clamp and cautery. The plan is this : 
Each tumor is seized by a pair of forceps and drawn well 
down. The clamp is then applied so as to embrace its base, 
the portion above the clamp is cut off with a pair of scissors 
curved on the flat, and a thermo-cautery iron, heated to a 
dull-red heat, is freely applied to the stump until all the ves- 
sels stop bleeding. 

In regard to this operation Allingham says: "In my 
opinion, this operation has little to recommend it. As regards 
danger to life, after all the issue of greatest moment, as far 
as my most careful researches have led me to a conclusion, it 
is quite six times as fatal as the ligature, properly and dex- 
terously applied." 

I use this plan in some selected cases — viz., where there is 
a large amount of superfluous skin around the anus, which is 
embraced in, or goes to make up, a part of the internal hsem- 
orrhoid, which falls under the variety of the mixed class. 



INTERNAL HEMORRHOIDS. 



147 



If this amount of skin is cut off, excessive bleeding may 
occur. If an incision is made around it and it is ligated, we 
are chary about cutting too close to the ligature, and there- 
fore we have much skin left and many ligatures to deal with. 




Mathews's pile forceps. 

By using the clamp, we can embrace all of this skin in a few 
sections, and, cutting close to the clamp, we can sear all the 
vessels. These are exceptional cases, however, and therefore 
I do not use the clamp and cautery often in my practice. 




Smith's elamp. 

The disadvantages of the method must be apparent. In the 
first place, the patient, coming into the operating-room, sees at 
a glance instruments which look like those of torture, or, if 
he does not see them, but has an inkling of their nature, he 




Bush's pile forceps. 

must regard a hot iron to be applied in the manner that it 
is during the operation as a very horrible thing. Even to a 
bystander the operation looks uncalled for. It can not be 
denied that the burning of this amount of tissue causes a 
very great deal of pain after the operation. No one can say 



148 DISEASES OF THE RECTUM, ANUS ; AND SIGMOID FLEXURE. 

that the iron has had full cautery effect upon every vessel, 
and therefore haemorrhage is more likely to occur than 
after the ligature. The period of convalescence is very long ; 
frequently more sloughing of the tissues than was intended 
takes place ; and we all know how natural it is for extensive 
scar tissue to follow burns ; therefore contraction of the 




Ashton's pile clamp-forceps. 

anus and rectum is to be feared. Having other operations 
at our command, which are more simple of execution and not 
fraught with so much danger, I can not see the advisability 
of using the clamp and cautery for the removal of haemor- 
rhoids except in a few selected cases. 




Benbam's pile clamp. 

Excision. — In speaking of excision of internal haemor- 
rhoids by the knife or scissors, Allingham says: "For my 
own part, I think it is one of our best operations, and I have 
now records of numerous cases in which I excised internal 
piles with remarkably good results." 

I think an author should consider the audience that he 
is addressing, especially in referring to dangerous surgical 
operations. In the hands of an expert operator like Alling- 
ham I can understand how an internal hsemorrhoid could be 
excised without a great deal of danger, but in the hands of 



INTERNAL HEMORRHOIDS. 149 

a man that was not ait fait it must be acknowledged that it 
would be a very dangerous operation. The following is the 
method that Allingham employs : "In performing excision I 
first gently, but fully, dilate the sphincter muscles, and em- 
ploy a retractor to keep the anus well open. I then seize the 
pile deeply by its base, cut it off below the level of the vol- 
sella, and do not let it go until all bleeding is arrested by 
torsion of the arteries. Rarely more than two vessels spout 
and require twisting. I wait for a little while to see that 
all bleeding has ceased, and then I treat the other piles in a 
similar manner." I think that those that have done much 
operating around the rectum will bear me out in saying that 
in but few hands could this operation be regarded as a safe 
one, and therefore can never become popular. 

Dilatation of the Sphincter Muscles. — This treatment of 
internal haemorrhoids is confined almost exclusively to France. 
I believe that Yerneuil was the first to suggest it. In the 
first place, I must agree with 
Allingham that the rectal 
physiology of Yerneuil gives 
no clew to the treatment, and 
I am satisfied that in no sin- 
gle instance where a full, 
well-formed internal hsemor- 
rhoid exists can dilatation of 
the sphincter muscle cure it. 
The relief that is obtained in 
haemorrhoids by this dilating 
process is not that it cures the 
hemorrhoids, but that it puts „, , ., ,. ... . 

x Thebaud's sphincter dilator. 

at rest an irritable sphincter 

muscle ; for generally in this condition there is some abrasion 
around this muscle, and a most wonderful relief is afforded 
by dilating it. I can not subscribe to the belief that through 
the dissections made by Verneuil we find sufficient evidence 
in the peculiar distribution of the veins, and the course they 
take in the coats of the rectum, to disprove the theory that 




150 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

constipation, sedentary occupation, drastic purgatives, pro- 
longed use of enemata, etc., can institute true haemorrhoids. 
His idea that the superior hemorrhoidal veins pass through 
" veritables boutonnieres musculaires" and that the muscu- 
lar button-holes have the power of contracting and causing 
such stasis and congestion in the superior hemorrhoidal 
veins as to cause the " primum mobile" in the formation of 
internal piles, I do not believe. Upon this theory was dila- 
tation of the two sphincter muscles suggested as a cure for 
internal haemorrhoids. Whatever might have been its success 
in France, I am sure it has failed of its object in America. 
This failure I attribute to the mistaken premise upon which 




Collins 



it was based. In a word, then, I believe haemorrhoids to be 
tumors in the formation of which the arteries as well as the 
veins play a part. I quite agree with Verneuil that the 
superior hemorrhoidal veins are connected with the portal 
system, and, in the main, form internal hemorrhoids, and 
that external piles are formed from the external and middle 
hemorrhoidal, which are not connected with the portal ve- 
nous system, and hence the two venous systems— por^aZ and 
general — are practically distinct at this point. This propo- 
sition is admitted, and yet we can not admit the absolute 
separation of the portal and general venous systems. I have 
been thus explicit on this point from the fact that confusion 
has often arisen over it, especially with students. Then, 
again, we must consider, even if we admitted the point that 
dilatation of the sphincter muscles would sometimes cure in- 
ternal hemorrhoids, that, if it was adopted as a plan of treat- 



INTERNAL HEMORRHOIDS. 



151 



ment, and indiscriminately nsed, very much damage would 
be done by it. There are three classes of patients upon 
whom we should be very chary about doing a forcible dilata- 
tion of these muscles : women, debilitated people, and the 
aged ; and yet these are the very people commonly affected 





Durham's dilator. 



>im's dilator. 

with hemorrhoidal trouble. In cases of fissure of the anus, 
or an irritable ulceration of the rectum, this is the ideal op- 
eration ; and the reason for its being so is easily understood. 
But to dilate a sphincter and break the fibers which keep 
up the irritation in the ulcer, to give the sphincter rest, and 
to cause the ulcer to 
heal, is a very differ- 
ent thing from dilat- 
ing a sphincter where 
well - formed tumors 
exist, with the expec- 
tation of dissipating 
them. There could be 

but one way in which they would disappear, and that would 
be by reabsorption. Dr. H. O. Walker, an eminent surgeon 
of Detroit, in a reprint published in 1887 on the treatment 

of anal fissures and 
haemorrhoids by 
gradual dilatation, 
reports some very 
beautiful cases that 
resulted favorably ; 
but in these, as in the other cases by different men who have 
written on the subject, I hold that there is no permanent cure 
where haemorrhoids exist, consequently the relief is but tem- 
porary. 




Eurand's dilator. 



152 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXUHE. 

Whitehead's Operation. — Every few years the medical profes- 
sion is treated to some new operation in surgery, the pres- 
entation of some much-wanted instrument, or the modifi- 
cation of some operation or instrument. The custom has 
become so prevalent of late that the profession looks with 
suspicion on all such, until an honest demonstration is had. 
I do not wish to appear in the role of discouraging any honest 
attempt to improve upon old methods, yet I have seen so 
many instances when such an endeavor amounted to almost 
a burlesque, that I must be excused for doubting until I am 
convinced. Scarcely has there ever been such a consensus of 
opinion among noted surgeons in regard to the surgical treat- 
ment of any disease as internal haemorrhoids, Gross, Erichsen, 
Van Buren, Allingham, Sr. and Jr., Ball, Wyeth, Straus, Bull, 
Copeland, Bush, Cook, Sir Benjamin Brodie, Syme, Curling, 
Quain, Ashton, Gowlland, Cooper, Goodsall, Gerster, Boden- 
hamer, and a host of other authorities agreeing that the liga- 
ture is the simplest and most radical cure for internal haem- 
orrhoids. Their statements are proved true by comparison 
with other methods, by its simplicity, by its freedom from 
danger, and by its radical cures. Latterly there have been 
many methods proposed for the treatment of piles, and they 
have generally met with the same fate — namely, abandonment 
by the profession after a fair trial. Among these may be 
mentioned the injection plan, crushing, divulsing the sphinc- 
ter muscles, etc. Mr. Whitehead, of Manchester (England), 
has lately proposed a new operation for the cure of haemor- 
rhoids which consists in the radical excision not only of the 
pile tumors, but also of the entire hemorrhoidal plexus . It 
would require more time than I would have in this chapter 
to enter into a discussion of the many things that have been 
saidjpro and con about this operation ; therefore I shall con- 
tent myself with a review of the operation itself as coming 
from the lips of the author, and which is now known as 
Whitehead's operation. 

He thus describes it: "The anaesthetized patient, having 
been placed in the lithotomy position, and the sphincters 




INTERNAL HEMORRHOIDS. 153 

paralyzed by stretching with the fingers, by the use of scis- 
sors and dissection-forceps, the mucous membrane is divided 
at its juncture with the skin around the entire circumference 
of the bowel, every irregularity of the skin being carefully 
followed. The external sphincters and the commencement 
of the internal sphincters are then exposed by a rapid dis- 
section, and the mucous membrane and attached haemor- 
rhoids, thus separated from the submucous bed on which 
they rested, are pulled 
bodily down, any indi- 
vidual points of resist- 
ance being snipped 
across, and the haemor- 
rhoids brought below the 

, . _, Curved pile scissors. 

skm. The mucous mem- 
brane above the hemorrhoids is now divided transversely in 
successive stages, and the free margin of the severed membrane 
above is attached as soon as divided to the free margin of the 
skin below by a suitable number of sutures. The complete 
ring of pile-bearing mucous membrane is thus removed." 
To this operation I shall prefer seven objections : 
1. The operation can not be advised except in selected 
cases. No distinction is made between the character of piles. 
It is a notable fact that the most dangerous of all internal 
haemorrhoids is the small capillary bleeding variety. Haemor- 
rhage may be so great as to endanger the life of the patient. 
Upon examination, the tumor is found to be located much 
higher up the gut than the ordinary venous tumor, and not 
larger than a raspberry. Would any one recommend White- 
head's operation for a condition involving so little pathologi- 
cal change either in the vessels or tissues \ And yet this is 
an internal pile, with dangerous symptoms. A touch of nitric 
acid to the spot, or a silk thread thrown around the base of a 
small tumor, stops all bleeding and cures the pile. Again, 
the patient who has phthisis complains of a tumor protrud- 
ing from the anus at each stool. The vitality of this person 
is much below par ; nutrition is very bad ; confinement to 



154 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

bed would be dangerous to his life. It would be folly to do 
the operation of excision in his case, which would mean non- 
union of cut surfaces, a flow of pus, weeks in bed, and a 
rapid advance of phthisis. By the use of the silk ligature 
the patient would not be confined to bed, and yet a radical 
cure of the pile would take place. 

2. An anaesthetic is necessary in every case. Of course 
no one would attempt to do the operation without an anaes- 
thetic. It would be impossible to do it. There are many 
persons to whom, from physical causes, it would not be safe 
to administer an anaesthetic. If it be said in reply that on 
such you could do no one of the other operations, this alone 
admits the argument. For the other methods it can be said 
that they can be practiced without an anaesthetic, and it is 
admitted that the cure would be radical — as, for instance, by 
the ligature. 

3. Full and complete paralysis of the sphincter muscles 
is necessary to do the operation. This is urgently advised 
by the author ; indeed, it would be impossible to accomplish 
the operation without this step. Those who have done much 
of this work recognize that it is a dangerous thing to prac- 
tice the divulsion of these muscles in all cases. Incontinence 
of faeces would often be witnessed if his advice was followed. 
The sphincter muscles in the female, as we have stated be- 
fore, yield much more readily than do those in the male, and 
are much longer in regaining their lost power. If inconti- 
nence of faeces resulted in consequence, as would often hap- 
pen, the result would be much more serious than the disease. 
Again, we witness in many patients who are enfeebled in 
health a lax condition of the sphincter muscles. This is es- 
pecially the case in tuberculosis. The operation would not 
be warranted in such cases. It can be said in favor of other 
methods that they can be practiced without divulsing the 
sphincter muscles ; hence in the cases cited they would take 
the place of Whitehead's operation. 

4. The operation is "difficult, tedious, and bloody." I 
know that the author has replied to this charge that he is 



INTERNAL HEMORRHOIDS. 155 

satisfied that it is an operation which can be easily performed 
by any surgeon possessing the average skill and intelligence, 
and to the charge that it is a bloody one he says that "it is 
never excessive haemorrhage ; such as I meet may very well 
take a subordinate position to other and more important 
considerations in the operation." 

To these two statements I wish to reply : (a) I am satisfied 
that all who attempt it will say that it is the most difficult of 
all the operations proposed for haemorrhoids ; (b) from the 
anatomical nature of the case, it is bound to be a bloody 
operation ; large vessels are necessarily divided and have to 
be secured ; (c) I quite agree with the author that haemor- 
rhage is a subordinate consideration to others in the opera- 
tion, for it is very difficult of execution and dangerous in 
many ways. 

5. If union does not take place by first intention, pus ac- 
cumulates, and the result must be an ugly one if not dan- 
gerous. If the parts are not freely reopened, pus is confined, 
pent up in a recent wound, and the danger of sepsis enhanced. 
If they are opened, healing must be by granulation, over an 
extensive surface, together with the fact that flaps exist that 
must be cut away, or they will hinder a good result. By the 
use of other methods no such condition of affairs could exist. 

6. The author recommends in doing the operation that 
the whole of the hemorrhoidal plexus be excised. This he 
makes absolute. To this I dissent. Just as well say that for 
a varicose condition of the veins of the leg the whole venous 
distribution of the limb should be excised. I can not agree 
that every dilatation here is a varicosity. No pathological 
change is evidenced in much of the plexus, and to remove 
these vessels that are simply distended with blood is bad sur- 
gery. It is a fact that they will return to their normal size 
and functions after the operation. This is witnessed after 
removing haemorrhoids by the ligature. Vessels that were 
engorged with blood resume their natural condition and ap- 
pearance. I once heard the elder Allingham say that after a 
satisfactory operation for internal haemorrhoids by the liga- 



156 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ture he had never operated a second time upon the same 
patient. This has been my experience. If the dilated veins 
that were left continued in a state of varices, the hemor- 
rhoidal tumor would have quickly reformed. 

7. It can be maintained that secondary hemorrhage is 
likely to occur after this operation, and that the results 
given by the author do not justify his claim. Recognizing 
that secondary hemorrhage might result in these cases, and 
that it is a bloody operation, Dr. Henry O. Marcy has devised 
a plan of securing all the important vessels involved in the 
operation by continuous encircling animal sutures before di- 
vision. This, in my opinion, is an admirable suggestion, and 
should be followed by any one doing the operation. Dr. 
Marcy wisely says : u This plan certainly diminishes the loss 
of blood and insures against secondary haemorrhages." The 
two things most dreaded in this operation. 

To the statement that the results do not prove the claims 
of the author, I would say that if the statements of many of 
the leading authorities of the world are to be believed, the 
ligature has proved to be the simplest, most effectual, and the 
freest from danger of all methods of operating for internal 
hemorrhoids. The results as obtained by Whitehead could 
not be better than have been obtained with the ligature. The 
idea advanced that the danger in the use of the ligature lies 
in the fact that septic infection is likely to follow is chimerical. 
As the tissue of this well-formed tumor is passed through by 
the ligature, a healthy granulating surface is left, which 
resists all septic invasions. If this were not so, why is it that 
authors are able to report thousands of operations for hemor- 
rhoids by the ligature without the least semblance of sepsis ? 
I had the honor to report to the surgical section of the Amer- 
ican Medical Association a short time ago one thousand 
operations for hemorrhoids by the ligature without a single 
death or a case of septic infection. After an experience of 
fifteen years in operating for this trouble, I have never oper- 
ated upon the same patient the second time ; have never tied 
a vessel during the operation. That it is a simpler operation 



INTERNAL HEMORRHOIDS. 157 

than Whitehead's can not be denied. That it is as free from 
danger is borne ont by facts. After a fair trial of his opera- 
tion I am forced to conclude : 1. That the operation meets 
the demand in but few cases. 2. When it is considered that 
a large proportion of subjects are unable to take an anaes- 
thetic, that some danger is always risked in giving an anaes- 
thetic, other methods, simpler in execution and freer from 
danger, can be practiced without the use of an anaesthetic and 
should be preferred. 3. As a full and complete paralysis of 
the sphincter muscles is necessary to the operation, great risk 
would be assumed in many cases. Other methods of cure 
would not necessitate this procedure. 4. From the fact that 
large blood-vessels have to be divided and that the rectum is 
a difficult place in which to secure arteries, the operation is 
in consequence "a bloody, difficult, and tedious one." 5. If 
union by first intention does not take place, as would likely 
be the case in strumous and other diatheses, the wound would 
be a large suppurating one, and sepsis would be invited. 6. 
The operation is not considered complete unless the whole 
of the haemorrhoidal plexus is removed. I submit that this 
involves an unnecessary amount of surgery and that the 
author's conclusions are based upon a wrong premise. 7. In 
view of the fact that the vessels are tied or twisted during the 
operation, and that the parts are in a diseased state, second- 
ary haemorrhage could be easily induced, and is a dangerous 
condition, especially so in the rectum. 



CHAPTER VII. 

THE LIGATURE IN THE TREATMENT OF INTERNAL HAEMOR- 
RHOIDS. 



I do not think it can be gainsaid but that the ligature 
is the easiest of execution, safest in its results, accompanied 
with less pain, and the convalescence quicker than any other 
method of treating internal haemorrhoids. Again, it can be 
asserted that most of the leading specialists and distin- 
guished surgeons of both this country and Europe prefer it 
to all other plans. It can be done under strict antiseptic pre- 
cautions, and statistics will show that fewer deaths have fol- 
lowed its use than any one of the other methods. Erich sen 
said that " all external piles should be cut off and all inter- 
nal piles tied. " I do not think to this day we can improve 
upon that injunction. The method has stood the test of time 
in the hands of the best surgeons, and the verdict to-day is as 
I have stated it. Allingham voices the sentiment of the pro- 
fession when he says : "Ido not think in the whole range of 
surgery there is any procedure worthy of the name of opera- 
tion which can show a greater amount of success or smaller 
death-rate than the ligature of internal haemorrhoids. " 

In this chapter I have given the names of some of the 
most eminent surgeons, both here and abroad, whose word 
must be taken with the greatest respect. Bushe never had a 
fatal case with the ligature. Sir Benjamin Brodie, who had a 
large experience, never lost a case. Mr. Syme never met with 
a fatal case. Ashton, Cooper, Van Buren, Bodenhamer, 
neither of whom ever met with a fatal accident. What lan- 
guage could be more to the point than that of Gross, our 
great surgeon, who said: "The operation by ligature is as 



THE LIGATURE IN INTERNAL HEMORRHOIDS. 159 

simple of execution as it is free from danger and certain in 
its results." We must judge of a tree by the fruit thereof. 
And these results, gathered from such eminent authorities, 
speak for themselves. 

The operation by ligature being the favorite one in my 
practice, I shall take the liberty of repeating here some of 
the precautions and rules that I observe in the operation. I 
shall also differ from some noted authorities upon the man- 
ner in which the ligature should be used. The report that I 
made to the American Medical Association, and to which I 
have referred in this chapter, of Some Observations after One 
Thousand Operations for Haemorrhoids, included both exter- 
nal and internal piles ; patients taken indiscriminately from 
hospital, dispensary, and private practice ; those done in cab- 
ins, as well as those in well-regulated infirmaries. Up to that 
time I had never met with a fatal accident. A short time 
after making that report I lost a patient from tetanus after 
ligating internal haemorrhoids. To the principle involved in 
the use of the ligature all surgeons are agreed, but the method 
of application is, to a certain degree, disputed. The method 
of operating at St. Mark's Hospital, and practiced at that in- 
stitution for more than fifty years, is described by Allingham 
as follows: "The patient, having been previously prepared 
by purgatives, is placed on the right side on a hard couch 
in a good light, and is completely anaesthetized. Then I 
always gently but completely dilate the sphincter muscles. 
This completed, the rectum for three inches is within easy 
reach, and no contraction of the sphincter takes place, so that 
all is clear like a map before you. The haemorrhoids, one by 
one, are to be taken by the surgeon with a vol sella, or pronged 
hooked fork, and drawn down ; then with a pair of sharp 
scissors separate the pile from its connection with the mus- 
cular and submucous tissues, upon which it rests. The cut is 
to be made in the sulcus, or white mark, which is seen where 
the skin meets the mucous membrane, and this incision is to 
be carried up the bowel and parallel to it to such a distance 
that the pile is left connected by an isthmus of vessels and 



160 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

mucous membrane only. There is no danger in making this 
incision, because all the larger vessels come from above, run- 
ning parallel with the bowel, just beneath the mucous mem- 
brane, and thus enter the upper part of the pile. A well- 
waxed, strong, thin-plaited ligature is now to be placed at 
the bottom of the deep groove you have made, and the assist- 
ant then drawing the pile well out, the ligature is tied high 
up at the neck of the tumor as tightly as possible. Be very 
careful to tie the ligature, and equally careful to tie the sec- 
ond knot, so that no slipping or giving way can take place. 
I myself always tie a third knot. The secret of the well- 
being of your patient depends greatly on this tying— a part 
of the operation by no means easy, as all practical men know, 
to effect. If this be done, all the large vessels in the pile 
must be included. The arteries in the cellular tissues around 
and outside the bowel are few and small, as they do not assist 
in the formation of the pile, being outside it. These vessels 
rarely require ligaturing. The silk should be so strong that 
you can not break it by fair pulling. If the pile be very 
large, a small portion may now be cut off, taking care to leave 
sufficient stump beyond the ligature to guard against its slip- 
ping. When all the haemorrhoids are thus tied, they should 
be returned within the sphincter. After this is done any 
superabundant skin which remains apparent may be cut off. 
But this should not be too freely excised for fear of contrac- 
tion when the wounds heal. I always place a pad of wool 
over the anus with a tight T-bandage, as it relieves pain most 
materially and prevents any tendency to straining." 

I have quoted this plan as detailed by Allingham, in his 
most excellent book on Diseas.es of the Rectum and Anus, 
because it is the most popular with all surgeons who use the 
ligature in operations upon internal piles, and that I expect 
to differ with the learned author on several important points 
in regard to the technique of the operation. 

Preparation of the Patient. — In these days, when modern sur- 
gery must obtain in all surgical operations, the rectal surgeon 
must give a very great deal of care to the preparation of his 



THE LIGATURE IX INTERNAL HEMORRHOIDS. 161 

patient before operating. I shall therefore be excused for the 
reiteration of my suggestions on some points in antiseptics 
which will refer especially to this operation. Cripps advises 
that the patient should have a dose of castor oil the last thing 
in the evening two days preceding that fixed for the opera- 
tion, and regards it as an unfortunate oversight in the previous 
edition of his work that he recommended the medicine to be 
given the evening before the operation. He says it is a mistake 
to do so, because the patient is often much disturbed at night 
in consequence, and is therefore in a very unfit condition for 
any operation in the morning. But I should reverse the thing 
as he has it now definitely settled. If a purgative is given two 
days preceding that fixed for the operation, the purgative, in 
my opinion, will accomplish very little if any good looking to 
the operation. Twenty-four hours is quite sufficient for the 
rectum, if not the sigmoid flexure, to become loaded with 
faeces again. Cripps evidently expects the injection of a pint 
and a half of warm water that he has administered the morn- 
ing of the operation to clear out the rectum. This it will 
likely do, but it will not clear out the alimentary canal. 
Therefore a better plan, I think, if you have your patient 
under observation for two days, is to give him a brisk saline 
purge on the second day prior to the operation, and on the 
evening before the operation, to prevent a reaccumulation in 
the small or large intestine, give him a gentle purgative pill 
at bedtime, which will not disturb him through the night, as 
castor oil would do, and his bowels will be moved in quite 
sufficient time for the operation next day. Just before going 
to the operating room it is best to have the patient take a 
hot bath, and not the evening before, as suggested by Cripps. 
One night is quite sufficient to undo all that has been accom- 
plished by the bath, looking from a surgical standpoint. Pre- 
suming, then, that the patient is in clean linen after his bath, 
he is put on the table, and the parts to be involved in the 
operation are then thoroughly washed with a bichloride-of- 
mercury solution (1 to 3,000 or 1 to 5,000). The parts are 

shaved if necessary. I prefer the washing here with the mer- 
n 



162 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

curie solution to ether, because the latter is accompanied 
with a burning sensation. Presuming that all the surround- 
ings are aseptic, the patient is put under the influence of the 
ansesthetic, after which he is placed in Sims' s position, with 
the legs drawn up toward the abdomen. I prefer this to the 
lithotomy position. In the latter it is necessary to secure the 
legs by Clover's or some other crutch, and those in the habit 
of operating with the patient in this position recognize the 
fact that the stoutest crutch sometimes gives way under the 
efforts of the patient while under the effect of an ansesthetic. 
An assistant, standing in front of the patient's knees, can 
easily hold them down. With a good light there is no diffi- 
culty in obtaining a perfect view of the rectum. I then intro- 
duce either a Cook or Mathews speculum and divulse the 
sphincter as widely as the instrument will distend it. This 
will be found to be an admirable help to the lingers, which are 
introduced after the speculum is withdrawn. Not much force 
is now required to distend the muscles ; but here I wish to 
emphasize that it is not my practice to break the muscles, and 
unless some such caution is given by the authors, the inex- 
perienced might think it necessary to do so. I distend until 
I feel a gentle relaxation. It will now be seen that the piles 
will present themselves, but not in their entirety. A mistake 
might be made here of ligating just what was in sight, think- 
ing this would complete the operation and effect a cure, but 
it is not so. It is best now to take hold of one of the large 
tumors with a four-pronged forceps, or clamp, and pull it 
forcibly down. It will then be seen that as much again as 
protruded is brought down. If this be repeated on the other 
side, granting that a hemorrhoid is found there, it will now 
be seen that the parts are everted and the other smaller tu- 
mors are brought into view. A pair of small retractors can 
be used in lieu of the forceps or clamps. These are given the 
assistant to hold while the operator secures the smaller piles, 
if any, and ligates them. It is important here to use two 
sizes of thread— a smaller size for the smaller tumors, and a 
larger. size for the large tumors. It has been my observation, 



THE LIGATURE IN INTERNAL HAEMORRHOIDS. 163 

in tying small internal piles with, a large ligature, that it 
slips off more easily than if a smaller ligature is used. The 
character of thread is a consideration. I think a stout linen 
thread quite as good as silk, but it must be understood that 
it must be so stout that it will not break with the hardest 
pulling. Much confusion arises, especially after transfixing 
tumors, from having the thread break. It is best also to have 
it well waxed, for the reason that it adds somewhat to its 
strength, but mainly that it makes the knot more secure. 
The smaller tumors then are tightly tied without transfixing. 
As to the large tumors, my method is this*: Before putting 
the patient on the table, I carefully examine the parts to see 
whether there is any superabundant skin around the anus. 
To my mind this is of great importance. If it is a smooth 
anus, with no disposition to folds or superfluity of true skin, 
then I consider any cutting whatever unnecessary. However 
the parts may look after the mass is protruded, because great 
bulging takes place, not only of the tumors themselves but 
also the general anatomy of the parts, I refrain from the use 
of the knife, but proceed as follows : While the anus is being- 
held open by the assistant with the aid of the retractors, I have 
the nurse flush the rectum, as far as exposed, with the bichlo- 
ride solution, with an irrigator (1 to 5,000). The small tumors 
are picked up and ligated in the manner just mentioned. The 
large tumors are caught well at their base, drawn stoutly 
down by the forceps, held there by the assistant, and a curved 
needle, threaded with stout silk, is passed immediately 
through the base. The needle is now cut away and the 
ligatures tied stoutly, first on one side of the tumor and then 
on the other. The operator should be very careful to draw 
the thread each time to see that the corresponding half is 
pulled before tying, else he may tie the wrong thread, and if 
he does, no strangulation of the pile takes place. Having the 
tumor tightly tied on each side, the pile is now cut off with a 
pair of straight, not curved, scissors. By so doing, you have 
an even surface, whereas if you used curved scissors the cut 
dips more in the center than at the sides, and might embrace 



164 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

more of the tumor than you proposed. It is a question how 
much of the pile should be cut away above the ligature. I 
think the advice usually given by authors is a little too care- 
ful — for this reason : If we only clip off a little portion of the 
tumor we leave the major portion or portions to be pushed 
back into the bowel ; consequently, that much more tissue is 
left to slough. If the tumors have been properly tied, I do 
not think the ligature is apt to slip, even if we cut tolerably 
close to it. The stump spreads out after the cut is made, and 
it is the rarest thing that it will slip off. Instead of cutting off 
one third of the tumor above the ligature, I am in the habit 
of cutting off two thirds, and I have never had haemorrhage 
result in consequence of this. The stumps, after being dusted 
with iodoform, are now reduced, the irrigation of the mercu- 
ric solution having been kept up more or less during the oper- 
ation. A piece of iodoform or bichloride gauze is now placed 
over the parts, one end of it being gently pushed into the 
anus and against the stumps. I am satisfied that by this ma- 
noeuvre the parts are kept from prolapsing. A large piece of 
absorbent cotton is now placed over the gauze and a T-band- 
age applied. The patient is then given a hypodermic injec- 
tion of one fourth of a grain of morphine and one one-hun- 
dredth of a grain of sulphate of atropine before he is taken to 
his room. This is repeated in one or two hours if necessary. 
If there has been no cutting done in this operation, the pain 
is very little, and frequently it is not necessary to give an opi- 
ate at all. I have found, after these operations, that sulphonal 
is a most excellent remedy to control the muscular spasm of the 
sphincter muscles, given in fifteen- or twenty-grain doses. If 
we have found that the patient has a superabundance of skin 
in the way of tags or folds, it will be necessary to do another 
operation. My plan is namely : The small piles are ligated in 
the usual way, and, presuming that they are everted or turned 
out, a four- pronged forceps, or a clamp, is made to catch 
them firmly at the base, encroaching more or less on the true 
skin, which is found coexistent with the parts. While the 
assistant holds it firmly out, a delicate knife is inserted on 



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OPERATION FOR INTERNAL HAEMORRHOIDS BY LIGATURE. 



THE LIGATURE IN INTERNAL HEMORRHOIDS. 165 

one side of the tumor at the junction of the true skin and mu- 
cous membrane and carried outward around the pile, includ- 
ing all the superfluous skin of that tumor, to the corresponding 
point at the other side. The hemorrhoid is then transfixed 
as in the manner suggested above, one thread being tied on 
the mucous side, tightly at the base of the pile, and the other 
thread is made to fall in the cut and is equally secured. The 
tumor is then cut off above the ligatures, leaving only enough 
to make the stump. Each large pile, which includes or is 
opposite any superfluous skin, must be treated in like man- 
ner. It will be seen that this operation differs materially 
from the one detailed by Allingham. In the first place, no 
cut is made in the so-called sulcus or white mark. My objec- 
tion to this advice is simply that it is nearly an impossibility, 
at least in the great majority of cases, to ever find the white 
mark, or to define exactly the sulcus. And as the superabun- 
dant skin is to be taken away in any event and by some manner, 
I think this is preferable to that suggested by Allingham. I 
think, too, that this manner of dealing with the superfluity of 
skin has its advantages over the other. It is easier for the 
student to comprehend what you mean, and you accomplish 
by one sweep of the knife what it takes two acts to do by the 
other. Then, too, you have a smoother surface left after the 
operation. 

According to Allingham's plan in cutting into the sup- 
posed sulcus, then ligating, the superabundant skin is after- 
ward cut off. In doing this it will be observed that often an 
irregular cut is made, and you have left a portion of skin or 
tissue next to the point of ligature, which, after cicatrization, 
leaves a ridge of scar tissue ; or if it be said that a clean cut 
is made, then you have done no more than has been suggested 
in the plan I mention. Another objection that I would prefer 
is the advice given that "this skin should not be too freely 
excised for fear of contraction when the wound heals." Now, 
I think this a very important point, but I beg to be on the 
other side of the question. One of the greatest annoyances 
after doing this operation is the swollen and ragged appear- 



166 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ance of this skin that was left. If I had any one suggestion 
above another to give the operator, it wonld be to make a 
sweeping cut of these tags. So apropos to this subject is a 
case that I have now under treatment, and which is but a 
sample of many, that I beg to detail it here. 

Case. — Mr. V., a countryman, came to me ten days ago to 
operate on him for large protruding piles. I did the oper- 
ation after the manner suggested, at the time removing two 
large superfluous folds of skin, together with two haemor- 
rhoids, and noticed at the time that there were two other tags 
of uninflamed skin around the anus. Although it is my cus- 
tom to remove all such, in this case, for some reason, I left 
these two. The case progressed nicely until to-day, when I 
was summoned to the infirmary by my assistant, who said 
that the gentleman was in great distress from having two in- 
flamed piles protrude from the rectum. I went to see him, 
and found that during the night he had had an action, when 
the haemorrhoids that I had tied had sloughed off, and the 
two tags of skin that I had refused to remove during the 
operation had taken on an active inflammation and were very 
much swollen and oedematous. I gave him some palliative 
treatment, and expect to cut them off to-morrow, which will 
necessitate the administration of an anaesthetic. 

This has occurred to me a number of times in my practice, 
and will invariably occur if all superfluous skin around the 
anus is not removed during the operation. It will also occur 
if but a small portion of the tag is cut off, in that the stump 
will take on inflammatory action. I know it is said that if 
we remove too much skin around the anus in this operation 
contraction will result. I believe that this is chimerical. I 
have practiced this manner of operating for many years, and 
I have never yet had contraction result which was sufficient 
to call for any dilatation whatever. 

The patient should be put to bed, and a light diet, consist- 
ing mostly of fluids, should be given for several days. At 
noon of the third day I usually order that the bowels be 
opened, and I believe that an aperient will do this best. A 



THE LIGATURE IN INTERNAL HEMORRHOIDS. 167 

Seidlitz powder, given on an empty stomach, will usually ac- 
complish the desired result. If it does not in a few hours it 
should be repeated. At the time that the patient feels that 
the bowels will move, all dressings should be removed, and an 
injection given of a pint or more of hot water. This insures a 
comparatively easy action. If they are disposed to act more 
than is thought necessary, they can easily be controled with 
a dose of paregoric, two to four drachms. If any pain should 
occur afterward in the abdomen indicative of an action, even 
up to the time that it is necessary to move the bowels again, 
paregoric should be administered. When the bandage is re- 
moved, and it is found that the cotton is sticking to the wound, 
it can be easily made to drop off by irrigating it with hot water. 
If some inflammatory action exists around the anus, the appli- 
cation of boiling hot water should be the method used to quiet 
it. Allingham says that if he finds any wool in the anus or 
sticking to the wound, a poultice is applied to soften the dry 
blood and assist in loosening the wool. I must take excep- 
tion to applying a poultice to fresh-made wounds. They are 
considered, and I think properly so, as a bed for germs, and 
I would not risk their application. Much more good can be 
accomplished by the use of the hot mercuric solution through 
an irrigator, often repeated. After the bowels have been 
moved on the second or third day, I have the parts irrigated 
one day with the mercuric solution, and the next day with 
the hot water carbolized, alternating with the two agents. 
After this irrigation I apply the iodoform gauze, without 
pushing it into the anus, over the gauze the surgeon's cotton, 
and then a T- bandage is applied. The parts should be dressed 
in this manner every day until the wound is healed. The liga- 
tures are apt to drop off from the sixth to the ninth day. A 
careful inspection of the parts should be made about this 
time if any ligature is left, for the reason that it is only held 
around a little piece of tissue. If this is so, a tenaculum 
should be slipped in the loop ; then, by pulling gently down, 
it can be clipped with a pair of scissors or with a sharp-point- 
ed knife. After all the tumors have sloughed off some sore- 



168 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ness will be felt, but I do not believe in the advice that an 
ointment should be applied. Grease is calculated to do a 
wound harm, certainly no good. Tell the patient to sponge 
the parts often with very hot water, and, if necessary, to use 
anything as a local application to induce the healing process 
if it is slow — blow either powdered iodoform or boric acid 
upon them ; then dress with dry cotton. The rectum should 
be syringed out once a day after the first dressings are re- 
moved until the patient is discharged. Retention of urine 
often takes place, in men especially, after this operation. To 
avoid any straining, it is best to use a soft-rubber Nelaton 
catheter until the patient is able to pass the urine. 

Patients will often say to you about the time the ligatures 
are separating that they notice some blood in their actions. 
This frequently alarms them, because they think "the disease 
is coming back again." We should anticipate this by inform- 
ing the patient that it may take place. While the patient is 
under your observation have him assume the recumbent po- 
sition. While feeling very comfortable on the third or fourth 
day, he will be very desirous of sitting up or walking around 
the room. Impress upon him the absolute necessity of re- 
maining in bed, for, if he should take any exercise, it will 
be noticed that the parts take on an inflammatory action. 
Some authors suggest that after the first week the finger 
should be anointed and passed into the bowel every day to 
make sure that no contraction results. I think that this 
habit would keep up an unnecessary amount of irritation 
and accomplish very little good. In my practice I have never 
found it necessary. It is an ugly one, to say the least of it, 
and I think it unnecessary. 

Complications. — Internal haemorrhoids are frequently com- 
plicated with other diseases of the rectum. 

Case. — A young lady, about eighteen years of age, was 
operated on for haemorrhoids by me, and the case progressed 
favorably until about the time I thought she was well enough 
to be discharged. A messenger came hurriedly to my hotel 
and said to me that my patient was in great pain and fright, 



THE LIGATURE IN INTERNAL HEMORRHOIDS. 169 

for the reason that there was a large mass protruding from the 
rectum. On my way down to her house I conjured my brain 
as to what the matter could be. She was lying in a strained 
position, being afraid to move for fear some accident would 
happen ; and when I inspected the parts I saw protruding 
from the anus a tumor the size of a walnut, having very much 
the appearance of a large internal venous pile. By running 
my finger alongside of it into the rectum I felt a pedicle, and 
traced it for two inches up the bowel where it was attached. 
I recognized, of course, that it was a polyp that had escaped 
my observation at the time of doing the operation. I was not 
so much to blame when it is remembered that these growths 
are frequently held high up, perhaps in the sigmoid flexure, 
their pedicle allowing them to float. I ligated the pedicle 
without trouble and clipped the polyp off, and yet I felt some 
embarrassment for the reason that I thought my patient 
would think that it should have been attended to at the time 
I operated on her for piles. If she did so think, she certainly 
thought right, and my only excuse to her was that w T e could 
not do too much ligating at one time. 

I cite this, therefore, to show that internal piles may be 
complicated with polyps, with fissures or ulcers, with fistula, 
impaction of faeces, or with cancer. If these complications 
are met, it is best to relieve, if possible, each and all of them 
along with the operation for internal haemorrhoids, save, per- 
haps, cancer. It is not necessary to detail the operations 
necessary to each individual case, as they are taken up in a 
separate chapter. 

One of the most serious complications may result from the 
operation itself. I allude to the sphincter muscle when it is 
in a feeble condition either from age or disease. Therefore it 
should always be borne in mind that in such a subject dilata- 
tion should be very carefully practiced. A patient may not 
censure you for a failure to cure him of internal haemorrhoids, 
but he would always blame you if you left him in a condition 
the result of incontinence. 

The authors frequently mention that a contraction of the 



170 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

parts may follow the operation for internal haemorrhoids, and 
therefore that this amounts to a complication ; but, in my 
experience as a rectal surgeon, I have never yet met with that 
complication, nor do I usually practice dilatation after the 
operation with either the finger or an instrument, nor do I 
understand how it can take place in many cases. The contrac- 
tion of tissue by a cicatrix is just as likely to draw the parts 
slightly outward as to form a contraction inward. At 
least I have never met with these cases as are detailed by 
some authors. Sepsis, including pyaemia, erysipelas, etc., 
is said to be a complication following this operation ; but 
if it is done under strict antiseptic precautions, it will not 
follow. 

Haemorrhage following Operations for Internal Haemorrhoids. — I 
do not believe that if the operation for internal haemorrhoids 
is done by the use of the ligature, properly applied, haem- 
orrhage would occur once in a thousand times. Haemor- 
rhage following this operation occurs from three sources : (1) 
Oozing from the cut surfaces in the tissues, which is prima- 
ry ; (2) slipping off of the ligature ; (3) cutting too quickly 
through. The first condition may arise from the fact that 
the gauze and the cotton have not been firmly packed and 
closely held to the parts. I believe that there is some art in 
applying the bandage to effect a close and tight compress. 
My method is this : Taking a four-inch bandage, eight feet 
long, I first tie it around the patient's body, just above the 
pelvis. The knot is made in front, leaving the short end six 
or eight inches long. The bandage is then passed between 
the legs and smoothly adapted over the cotton and then 
passed under the bandage around the waist at the back, then 
carried backward over the same line to the front again, and, 
passing over the front of the bandage, carried back the same 
way as before, being smoothly applied over the cotton each 
time and then tied to the short end that is left. No pins are 
used. It can be smoothly and tightly applied, thereby pre- 
venting any haemorrhage from the cut surfaces. 

Haemorrhage may result from the slipping of a ligature if 



THE LIGATURE IN INTERNAL HEMORRHOIDS. 171 

it has not been securely placed, or if the pile has been cut off 
too close to the ligature. 

Case. — A young man came into my office complaining that 
he had just noticed the descent of a pile. I examined him 
and found a soft hemorrhoidal tumor presenting with a nar- 
row base. I slipped a thread around it and ligated the pile. 
With a pair of straight scissors I then cut it off, the little 
stump slipping back into the rectum. Being busy, I sent him 
into another room to lie down on the couch until I could see 
him again. I directed my assistant to remain in the room 
with him. In about one hour I was informed that he had 
grown restless, remarking that he felt all right and that he 
would go home. He took a street car and started home, 
which was a distance of at least thirty blocks. When he got 
into his door he was so weak that he fainted, and his wife, in 
pulling off his boots, discovered that they were full of blood. 
In a little while he was able to tell her what had taken place, 
when she immediately telephoned me that he was bleeding. 
Thinking that it did not amount to much, I delayed going 
until I received a second summons. Just then a doctor friend 
came in. I told him the circumstance, and he drove with me 
to the house. When we arrived there, we found the man in 
nearly a dying condition from haemorrhage. He had passed 
in two evacuations at least a gallon of blood. The extremi- 
ties were very cold, profuse sweat was over the body, his 
pulse could not be counted, and he was speechless, looking 
indeed like a dying man. It was after dark, and we had only 
a coal-oil lamp at our service as a light. While some one held 
the lamp I divulsed the sphincter, and could see the pumping 
of a vessel at the point where the ligature had slipped off. 
With a long artery forceps I secured it, and, by the aid of my 
doctor friend, put a ligature round it. This stopped all bleed- 
ing and the man made a good recovery. 

The case shows how a small operation may result disas- 
trously if not properly attended. In my experience of six- 
teen years in this special line of surgery, I have met with 
but one case of secondary hemorrhage. It occurred as 



172 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

follows : A gentleman came to me from Frankfort, and was 
operated on for an ordinary case of internal haemorrhoids. 
Everything did well until the seventh day. The evening of 
the sixth I was at the infirmary, and he said to me that he 
had been nauseated all day, and he looked very pale. I did 
not, however, put much stress upon it. I was sent for at 
eleven o'clock the next day to see him. His remark to me as 
I went into the room was : " I feel just as I did when I took 
chloroform. I am very dizzy." I suspected the trouble, and 
just at this time he said tome: "Please allow me to stand 
up that I may get the fresh air." He suited the action to the 
word and was up before I could reply. Then he said quickly, 
"My bowels are moving," although there was a bandage on 
him. I had seen by this time, however, the blood trickling 
down his leg. I thought it best to allow him to sit on the 
commode, and as he did so over a quart of blood passed. We 
immediately lifted him into the bed, and I explained the 
situation to him, telling him that his condition would not 
warrant the administration of an anaesthetic, and that he 
must stand what I was going to do, for it was to save his life. 
I immediately divulsed the sphincter muscle and tamponed 
the rectum. All haemorrhage ceased. The tampon was al- 
lowed to remain Hve days and was then removed. 

Apropos to this subject, it is well to consider that haemor- 
rhage from the rectum may occur from a number of causes, 
and when met is a serious thing to deal with. It is not often 
that a bleeding vessel can be secured as was done in the case 
just reported. If any diseased condition exists or the haemor- 
rhage is secondary, it is a loss of time to look for the bleeding 
surface. Therefore I am not in the habit of following the 
directions of many who write on this subject — to stop haemor- 
rhage from the rectum by hunting for the bleeding vessel or 
local spot and making application of some caustic, such as 
nitric acid, carbolic acid, persulphate of iron, etc. Haemor- 
rhage in this locality is too dangerous a symptom to deal with 
in this manner. 

Causes of Hemorrhage. — The causes of haemorrhage from 



THE LIGATURE IN INTERNAL HEMORRHOIDS. 173 

the rectum may be briefly named as follows : 1. Haemor- 
rhage following the ligation of internal piles. 2. From ul- 
ceration of the bowel. 3. From capillary haemorrhoids. 4. 
From a hemorrhagic diathesis. 5. From the tearing off of 
polyps. These, in my opinion, constitute the general causes 
of hemorrhage requiring surgical interference. Sir Astley 
Cooper lost a patient from haemorrhage after ligating a pile. 
The elder Gross reported a similar case. There are three 
causes for haemorrhage following this operation in addition to 
those already given : 1. The division of a vessel or vessels at 
the time of operating, which might sometimes follow the op- 
eration by clamp and cautery. 2. Puncture of a vessel in 
transfixing the tumor, the method so strongly advocated by 
Yan Buren. 3. In sloughing of the pile. 

But it is not the causes of haemorrhage that I desire to 
deal with especially in this chapter, but the method of ar 
resting it. In my opinion, in excessive haemorrhage from 
the rectum there are but two ways to be considered for its 
stoppage : One, ligation of the vessel, or the mass in which 
the vessel is included. Second, by the use of the tampon. 

There are a great many diseases of the rectum requiring 
surgical treatment ; hence it is no wonder that haemorrhage — 
both primary and secondary — occurs after these operations. 
It is recognized that in the division of a stricture of the rec- 
tum located as high as four inches, or a finger's length, above 
the external sphincter muscle, the main branch of the middle 
and inferior haemorrhoidal artery is frequently cut. Because 
of the distance within, the difficulty of reaching the severed 
end of the vessel is very great. Together with the fact that 
it is imbedded in a pathological structure, it is impossible to 
ligate it, and it becomes a necessity to tampon the rectum to 
stop the haemorrhage. In operations for fistula in ano the 
inferior or external haemorrhoidal artery is often severed, and 
although it is generally secured during the operation, sec- 
ondary haemorrhage sometimes follows. This has occurred 
in my practice several times in the past few years. It is not 
infrequent that polyps break off from their delicate attach- 



174 DISEASES OF THP RECTUM, ANUS, AND SIGMOID FLEXURE. 

merit and, being fed with a good-sized artery, violent bleed- 
ing will sometimes take place. Except in one instance, I 
have never been able to secure the broken pedicle and ligate 
it. In these cases the tampon must be resorted to. 

The rectum being a favorite seat for cancer, it is not un- 
common that haemorrhage is so violent from the growth as to 
endanger life. These cases invariably require pressure to 
stop the bleeding. Several years ago I reported three cases 
of dangerous haemorrhage occurring in my practice from ar- 
tery rupture in the rectum. The tampon was used in two of 
these cases. Where the haemorrhage is not excessive, but 
constant, I am more and more persuaded that such cases are 
often treated for dysentery, the physician relying on the pa- 
tient's story, and putting but little stress on the loss of blood, 
or, as is more likely, looking upon the case as one of " bleed- 
ing piles " and leaving it alone, when in truth it is a dangerous 
condition. Surgeons who have divided fistulous tracts run- 
ning high up the rectum have been impressed with the great 
amount of blood that is sometimes lost. Gowlland, of St. 
Mark's Hospital, is so chary about dividing even the mucous 
membrane of the rectum that he has devised an operation to 
avoid this haemorrhage. He explained it to me as follows, 
to be used in dividing internal fistulae : It consists in the in- 
troduction of a long probe, threaded with a ligature to the 
very top of the sinus, pushing it through the mucous mem- 
brane, then bringing both ends of the thread out of the anus. 
Over these he pushes a piece of hard-rubber catheter, and, 
pushing it tightly up the threads until it comes in contact 
with the mucous membrane, it is secured by a small piece of 
wood stuck in the end of this temporized clamp. 

In case I cut the mucous membrane of the rectum to any 
extent, I am in the habit of using the tampon to prevent 
haemorrhage. Although I have used Mr. Gowlland's method 
several times with success, I have seen one case of proctitis 
result in such violent bleeding as to require the tampon to 
stop it. I preferred pressure here for the reason that it 
would do less damage to the already inflamed membrane 



THE LIGATURE IN INTERNAL HAEMORRHOIDS. 175 

than a caustic. Foreign bodies in the rectum, by their pres- 
ence, or attempted removal, may result in the wounding of 
the blood-vessels, in which case either the ligature or the 
tampon would have to be resorted to. Allingham's method 
of plugging is, namely: " Having passed a strong silk liga- 
ture through your cone-shaped sponge near its apex, bring 
it back again so that the apex of the sponge is held in a loop 
of the thread. Then wet the sponge, squeeze it dry, and 
powder it well, filling up the lacunae with iron or other as- 
tringent. Pass the forefinger of your left hand into the 
bowel and, upon that as a guide, push up the sponge — ajDex 
first — by means of a metal rod, bougie, pen-holder, or a 
rounded piece of wood, if you can get nothing better. Now, 
this sponge should be carried up the bowel at least five 
inches, the double thread hanging outside the anus. When 
this is so placed, fill up the whole of the rectum below the 
sponge thoroughly and carefully with cotton-wool, well pow- 
dered with the alum or iron. When you have completely 
stuffed the bowel, take hold of the silk ligature attached to 
the sponge, and while with one hand you pull down the 
sponge, with the other hand push up the wool. This joint 
action will spread out the bell-shaped sponge like opening an 
umbrella and bring the wool compactly together. If this is 
carefully done, no bleeding can possibly take place either 
internally or externally. Half-measures in these cases are 
worse than useless, as valuable time is thereby lost. This 
plug should remain in at least a week, and it may remain in 
a fortnight or more." 

I tried this method of tamponing the rectum for several 
years, and found it a very awkward procedure. In the first 
place, with only the finger as a guide and your sponge filled 
with iron or other astringent, it is a most difficult matter to 
push the sponge into and then up the rectum. Then, after it 
is fully passed, it necessitates adding additional cotton below 
it. Again, the iron is very apt, in its effect upon the thread, 
to destroy it, and thereby you would lose the use of the 
thread when you desired to extract the sponge. A simpler 



176 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and better method than this is the one I now practice. The 
articles I use for the purpose, and always carry in my case, 
are : Absorbent cotton, a piece of hard-rubber tubing, a stout 
cord, and a bottle containing MonseVs solution. Begin- 
ning at about one inch from one end of the tubing, which 
should be eight inches long, I begin to wrap firmly with the 
absorbent cotton for fully five inches. The tampon is made 
to resemble a double cone in shape, or two cones placed to- 
gether with their widened ends in apposition. The circum- 
ference of the tampon in the middle should be fully six 
inches, gradually tapering toward each end. The whole tam- 
pon is then firmly wrapped with a stout cord which is tied at 
its lower end, and a double thread allowed to hang out of the 
anus. It might be said here that the same objection that I 
preferred to the other method that I described was that the 
iron would destroy the thread. That is all right if it should 
do it in this instance, for, if the tampon remains but a short 
time in the rectum, the cotton becomes so thoroughly soaked 
with the liquids that it hugs tightly the rubber tubing, and 
does not separate from it at any effort at pulling. The tam- 
pon is now soaked in MonseVs solution of iron diluted one 
third or one half with water. The rectum is quickly syringed 
out with a hot mercuric solution, the patient anaesthetized, 
unless too feeble to warrant it, the sphincters are freely di- 
vulsed with a dilator, and the tampon pushed up the rectum 
fully five inches. Pressure is then made on the tubing, and 
the speculum or dilator then removed. The whole of the live 
inches of the rectum is distended by the tampon, thereby re- 
ceiving its pressure and the astringent effect of the iron. The 
rubber tube answers two purposes : 1. It allows the escape of 
gases, and the injection of water through it, if necessary. 2. If 
haemorrhage takes place, it is at once indicated by the flow of 
blood through the tube. I prefer this method of making and 
using the tampon over Allingham's for several reasons besides 
those already given : 1. His, being made of sponge and pulled 
down to a balloon-shape, is apt to lose its own proper shape 
and assume that of a ball, therefore is less likely to exert equal 



THE LIGATURE IN INTERNAL HEMORRHOIDS. 177 

pressure. By the other method a firm pressure is kept up all 
the time. 2. In removing the tampon of sponge, you have 
to rely solely upon the cord, which may pull through or 
break. In the other, a firm hold can be taken on the solid 
tubing of the tampon proper, and by a steady pull it comes 
easily out. Allingham says that this plug should remain in at 
least a week, and it may be retained a fortnight or more. I 
am in the habit of allowing the tampon to remain in the rec- 
tum but four days, even when it has been put in under anti- 
septic precautions and drainage allowed through the rubber 
tube. Sepsis is invited by allowing a tampon filled or satu- 
rated with nasty discharges to remain in the rectum, espe- 
cially so when there is a lesion. This method of plugging the 
rectum has been used by me for ten years, and I am satisfied 
that in a number of cases I have saved life by its use. Any 
one using the one method, and then the other, will see at once 
the value of the latter. 

Mr. Gowlland has designed some special tubes, made of 
vulcanite, shaped like a bougie, seven inches in length and 
about one inch in diameter. The base terminates in a rim 
which is perforated so that it can be sewn to a bandage. It 
is to be seen that a sponge or cotton would have to be wrapped 
around it, and wool packed into the rectum after it is intro- 
duced. I have never had the opportunity to use them, con- 
sequently can not decide as to their merit. If sudden haemor- 
rhage attacks the rectum, from whatever cause, the muscles 
should be dilated and a quick inspection made of the rectum. 
If a bleeding vessel can be seen and the parts are not diseased, 
it is the best plan, of course, to try and secure it by ligature, 
but I always feel safer, even in instances like this, after I have 
tamponed the gut. 

As a summary, I would desire to say that I have operated 
over one thousand times for haemorrhoids by the ligature. I 
have never had to operate the second time upon the same pa- 
tient for the affection, have never had an unnatural contrac- 
tion around the anus as the result of the operation, nor had 
ulceration or stricture to result. I have had in this time one 
12 



178 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

case of tetanus, superinduced by a debauch, which recovered, 
and one case of tetanus which terminated fatally. Have had 
one case of secondary haemorrhage occurring on the seventh 
day, which required the use of the tampon, and one case of 
primary haemorrhage, by the slipping of the ligature, which 
also required the introduction of the tampon. I do not be- 
lieve that had I used any other method as a constant thing I 
could report so favorably. 



CHAPTER VIII. 

FISTULA IN ANO. 

It is a question with surgeons which is the most common 
rectal disease that affects the adult. Allingham, with his 
vast experience, says fistula is. The records of my books 
will show that in my practice internal haemorrhoids are more 
common than fistula. I believe that if we take them indis- 
criminately the difference in favor of the one or the other 
would be very small. Patients are alarmed and look hor- 
rified when they are told that they have fistula ; when in- 
formed that they have piles, they usually regard it as a small 
affair. Fistula and piles are frequently combined ; indeed, 
one can produce the other. Operations are sometimes done 
for external piles, and a fistula is left which was not detected 
at the time. The surgeon should never be content with 
making a diagnosis of one rectal disease until he has thor- 
oughly searched for any other that might exist. I believe 
that men are more subject to fistula, and women more subject 
to piles. Fistula in ano is said to be a disease of middle life, 
but I have operated for it in the very aged and in an infant 
three weeks old. 

Case. — My friend, Dr. George W. Griffith, asked me to 
see with him an infant only three weeks old that had some 
rectal trouble. When we examined the little patient to- 
gether, we found a distinct external opening about half an 
inch from the anus, which communicated with the bowel. It 
appeared to me that it must have been congenital. The sinus 
was laid open and dressed as is usual in such cases. I be- 
lieve this to be the youngest case of fistula on record. 

Causes. — Fistula in ano is, in my opinion, invariably pre- 



180 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ceded by or is the result of an abscess. Now, it is very true 
that patients suffering from a scrofulous or tubercular diathe- 
sis may have the tissue around the rectum break down be- 
cause of this predisposition, and yet we find it assuming the 
nature of an abscess. Taking an abscess to mean strictly u a 
cavity filled with pus," we are to presume that this pus has 
been produced by one of the four pus-producing micro- 
organisms. To hold to this strict pathology, fistula originat- 
ing from the so-called "cold" abscess, or tubercular degenera- 
tion of tissue, could not be called an abscess at all, and yet for 
an understanding of the pathology or causes of fistula in ano 
I think it best to say that the disease originates with an ab- 
scess. Therefore the physician should always take the pre- 
caution in dealing with an abscess around the rectum to say 
to the patient or friends that the trouble in a large percentage 
of cases results in fistula. For, if an abscess is opened, al- 
though the patient is given instant relief from pain, if a fist- 
ula results he caD not understand why you refuse to tell him 
that such a disease would follow, and he would likely attrib- 
ute it to the ignorance of the physician and employ some 
one else to attend to the fistula. When an abscess is of the 
acute variety it is. very painful, and the hard tumor can be 
easily circumscribed. Such abscess is usually found in ro- 
bust and healthy people, and especially in those in adult life. 
The so-called " cold " abscess, or that resulting from a degen- 
eration of tissue, is not painful at all, and can not be circum- 
scribed. This is a dangerous form of abscess. In either 
form, be it acute or chronic, it should be opened and the con- 
tents freely evacuated. It is a difficult thing to say some- 
times what has caused the abscess around the rectum. It is 
true that traumatism might result in such inflammation as to 
give rise to suppuration, but in many cases patients tell us 
that no wound or blow or injury of any kind has been re- 
ceived. Anything acting as a long-continued irritant may 
produce inflammatory action in this neighborhood ; therefore 
it is to be supposed that dry faeces held in the rectum, re- 
maining there or passed with a straining effort, may give rise 



FISTULA IN ANO. 181 

to an abscess. That a blow may cause such an effect the fol- 
lowing cases nicely illustrate : * 

Case I. — Some time ago a physician living in the west end 
of this city asked me to see a gentleman with him who was 
suffering the most intense agony in the neighborhood of the 
rectum. Upon arriving at the house, we found him rolling 
and tossing on the bed — physically a perfect man. He said 
that a few days previous he had stepped into a saloon to take 
a glass of beer. While standing in a bent position talking to 
the bar-tender, a friend came in and, slipping up behind him, 
dealt him a vigorous kick over the buttocks. He said it hurt 
him intensely at the time, and he told the man that he had seri- 
ously injured him, although it was done in a playful manner. 
The next day he began to suffer intense pain in the rectum. 
This continued for several days, and the physician saw noth- 
ing externally to indicate an abscess. I introduced my finger 
through an irritable sphincter muscle, and, about two inches 
above, detected a large abscess pointing into the rectum. I 
suggested that we put the man under an anaesthetic and pro- 
ceed to evacuate the pus. Thinking that it would be best 
to get an external opening, thereby preventing an internal 
fistula, I ran my knife alongside of the sphincter muscle, 
outside and in about one inch, struck the cavity, and let 
out a great quantity of pus. He was relieved at once of 
all pain, and the healing process went on and no fistula re- 
sulted. 

Case II. — I have now under treatment a gentleman with 
the following history: Mr. Gr., a farmer, aged forty-five, 
health robust, was standing on the street conversing when a 
friend approached him from behind and "bucked" him 
severely. The kick was received directly over the coccyx. 
He experienced violent pain at the time and expressed the 
opinion that he was seriously hurt. Upon his return home 
the pain was aggravated and he was incapacitated for work. 
A tumor appeared at the site of injury, with all the symp- 
toms of an acute abscess. He did not consult a physician, 
expecting every day that the abscess would open without 



182 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

lancing. At the end of the fifth week he came to my office, 
and, after examining him, I advised that it be immediately 
opened. To this he reluctantly consented. In lancing it 
I discovered that the pus had burrowed deeply, seeking no 
egress externally. About four ounces of pus was evacuated. 
I advised him to go home and rest, warning him, however, 
that he might expect an extensive fistula to result. At this 
time he had a very bad color, an elevated temperature, and 
an accelerated pulse. After several days he returned to me 
in a very bad condition. A large fistulous opening, dis- 
charging pus freely, some fever, coated tongue, etc. I ad- 
vised an immediate operation, which was done. For several 
days he seemed to do well, but upon the fifth morning he 
had two severe rigors, which I considered septic. The wound 
looked badly, and altogether he was in an unpromising con- 
dition. At this time Dr. Ap Morgan Yance saw him with 
me. He continued for some days in this condition, but 
things took a favorable turn, and he is now out of danger. 
The wounds inflicted were necessarily large, but are now 
healing rapidly. The patient carries an accident policy for 
ten thousand dollars. 

It is often said that a constipated habit is one cause of 
this trouble, and yet we meet it in persons who have been 
perfectly regular, so far as the bowels are concerned, all their 
lives. One of the worst cases of fistula in ano that I have 
ever met was in a society woman of this city who seemed to 
be angered at herself or Nature for having the trouble. She 
said she could not understand why she should be so afflicted, 
because her mother had told her from infancy the importance 
of having a daily evacuation of the bowels, and she had re- 
membered the injunction all her life, and had strictly fol- 
lowed it. I am inclined to think that diarrhoea and dysen- 
tery are sometimes the cause of abscesses by their long-con- 
tinued irritation of the mucous membrane and the adjacent 
structures. Foreign bodies which have passed through the 
alimentary canal and lodged in the rectum, or such as have 
been pushed into the rectum, may, of course, excite to ab- 



FISTULA IN ANO. 183 

scess. Therefore sometimes we can trace the cause of the 
abscess which we are called to treat, but in the majority of 
cases I do not believe that we can do so. Some authors 
speak of superficial and deep abscesses. I believe this to be 
a good division, especially looking to the treatment of them. 
An abscess may be small and, being in a location that does 
not affect the sphincter muscle, may not cause much pain, 
may break of its own accord, and yet this is the starting- 
point of a fistula. It must be understood that the great ma- 
jority of fistulse are progressive, and, whether they start with 
a very large abscess or with a very small one, may eventually 
be a serious affair. 

Cripps says: "I would advise any surgeon who may be 
still in doubt as to the starting point of rectal fistula to keep 
memoranda of all the cases of ischio-rectal abscess he is 
called upon to treat, and I will undertake to say more than 
one half of these end in the establishment of a fistula in ano ; 
and, further, if, when he is consulted by patients with fist- 
ula, he will take the trouble to question them carefully, he 
will find that their trouble almost invariably commenced with 
symptoms of rectal abscess." 

I do not wish to deny that more than one half of the ab- 
scesses which originate in the ischio-rectal fossae end in fist- 
ula, but as to its being the starting-point in more than half 
of the abscesses around the rectum I do not believe. Cer- 
tainly, if we take into consideration the superficial as well 
as the deep abscesses, the major portion of them do not be- 
gin in this fossa. As to the latter part of the quotation — 
namely, " that the patient will find that the trouble almost 
invariably commenced with rectal abscess " — I wish to exclude 
the adverb and say that the trouble invariably commences 
with an abscess. I have never seen a single case of fistula 
in ano that commenced in any other way. 

There are three varieties of abscesses found in this lo- 
cality : First, the marginal abscess, situated just at the ori- 
fice ; second, those which form in the loose connective tissue 
around the rectum, tolerably high up, in what Bichet called 



184 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

" the superior pelvi-rectal space"; third, those found in the 
ischio-rectal fossae. 

I believe that the commonest seat of abscess around the 
rectum is in the loose connective tissue. 

Case. — A short time ago I was called in consultation 
with a physician of this city to see a patient who gave the 
following history : He was a plumber by trade, and said that 
the evening before he attempted to lift a boiler into position, 
and the weight was so great that it was with the utmost dif- 
ficulty that he could lift it at all, and during the attempt he 
felt something give way in the abdomen. He immediately 
let the boiler fall, and he himself fell to the ground in pain. 
He was carried to his home and put to bed, and shortly 
afterward began to refer the pain to the rectum. His physi- 
cian sent for me the first night, and we saw him together. 
The patient said that he was suffering a very agonizing pain 
inside the rectum, which had begun with the accident in lift- 
ing the boiler. I inserted my finger, but at no one point did 
he complain of great sensitiveness. We gave the man a hy- 
podermic of morphine, and, taking his history into considera- 
tion, we thought that very likely he might be suffering from 
intussusception of the bowel. Therefore, to anticipate it, we 
ordered a brisk purgative, more as a point in diagnosis than 
anything else. The purgative having no effect at the time ex- 
pected, I gave him six grains of calomel, to be followed shortly 
after by one ounce of C. O. salts. The next morning his bow- 
els had freely moved, which cleared up the diagnosis so far as 
the intussusception was concerned. But the pain in the rec- 
tum increased, and it required very large doses of morphine 
to control it. This man held an accident policy in one of the 
leading companies, and they, being informed of the accident, 
sent their own physician to investigate his case. Seeing him 
at the stage that I have mentioned, no one could tell exactly 
what nature of injury had been inflicted. After five more 
days I introduced my finger into the rectum again and felt 
a well-defined inflammatory tumor, which I at once took to 
be jan .abscess, though I could not at that time detect any 



FISTULA IN ANO. 185 

fluctuation. We agreed to wait another day for further de- 
velopments, partly because I did not desire to evacuate the 
pus through the bowel, for fear of establishing an internal 
fistula, and yet the tumor was so high up, situated above the 
levator ani muscle in the "superior pelvi-rectal space," that I 
feared I would not be able to reach it by running the knife 
in from the outside of the bowel. So, after waiting two more 
days, I concluded to go down through the tissues on the 
outside of the sphincter muscles, and in making the cut I 
reached the cavity at the depth of about one inch and evacu- 
ated a quantity of pus. 

This case illustrates two points : First, that, although it 
was a very large rectal abscess, it was not located in the 
ischio-rectal fossa ; second, that these abscesses can be evacu- 
ated from the outside instead of the inside of the bowel, 
thereby securing good drainage and doing away with the risk 
of internal fistula. There was a very nice legal point involved 
here — namely, was this man's rectal abscess due to the attempt 
he made to lift the boiler, or, had he died of sepsis, would the 
accident company have contended the point ? I would have 
to affirm that I believed the accident caused the abscess. I 
have never seen an abscess around the rectum aborted. Sup- 
puration is the result, and the rule should be that just so 
soon as pus is detected it should be evacuated. I do not like 
the terms idiopathic and traumatic as applied to abscesses. 
In the first. place, in regard to abscesses arising in weak per- 
sons or in tubercular subjects, the term is really a misnomer, 
for the contents of such cavities, as I have intimated, are not, 
in the true sense of the term, pus at all. Sepsis is not to be 
feared from such, unless they are exposed to the air by an 
incision ; therefore I believe all abscesses proper are caused 
by inflammation, generally the result of traumatism. In 
cases of stricture of the rectum we frequently have secondary 
abscesses which result in fistula ; and physicians sometimes 
make the great mistake of operating for these fistulous si- 
nuses and leaving the stricture. The wounds made would 
never heal as long as the original cause of this condition ex- 



186 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

isted, and therefore we inflict upon patients a worse condition 
than existed before the operation for fistula. I wish also to 
add that in cases of fistula in ano, complicated by stricture of 
the rectum, or vice versa, an operation upon the stricture will 
not benefit the fistulse, nor will an operation performed for 
the fistulse benefit the stricture. It is a bad condition of 
affairs and must be dealt with with a good deal of discretion. 

Case. — A railroad man, about thirty-five years of age, of 
small stature and feeble health, was referred to me for treat- 
ment. When I put him upon the examining table I saw all 
around the anus, in the perinseum, buttocks, etc., a great num- 
ber of small abscesses, together with a number of openings of 
fistulse. I introduced my finger and detected a very feeble 
external sphincter muscle— indeed, it did not respond to the 
touch at all — and above it a very close stricture. I was satis- 
fied, by the answers that were given to my questions, as well 
as by the physical evidences in the case, that the stricture was 
of a syphilitic origin. Now, this man was in a deplorable con- 
dition. It was with difficulty that he could have an action at 
all, and the discharge of pus from the numerous abscesses 
was very abundant. His general health had greatly failed 
him. I took the case under careful consideration and argued 
thus : If I dilate or break this stricture, he will have no con- 
trol over his actions at all ; if I lay open the fistulse, the 
wounds will not heal. So I could see nothing to do in this 
case but advise a colotomy. This he refused. I contented 
myself, therefore, in opening the small abscesses and in get- 
ting, as far as I could, a free drainage of pus, and suggested 
that he take a good tonic course of treatment. 

Conservative surgery should obtain just as well in dealing 
with diseases of the rectum as with disease anywhere else, and 
in cases where we are satisfied that we can do no good by an 
operation it should not be attempted. The method of dealing 
with abscesses around the rectum is very simple. If we are 
waiting for the formation of pus, large and very hot poul- 
tices of ground flaxseed should be applied often to the parts 
and covered with oil silk, to retain the heat. The pain should 



FISTULA IX ANO. 187 

be quieted by hypodermic injections of morphine. When 
fluctuation is detected, the abscess should be opened. The 
method to be employed here is of some concern. Allingham 
suggests the following plan: " Place the patient on the side 
on which the swelling exists, pass the forefinger of the left 
hand well anointed gently into the bowel, then place the 
thumb of the same hand below the swelling on the skin. Now 
make outward pressure with your finger in the bowel, and 
you render the swelling quite tense and defined, it being, in 
fact, taken between your finger and thumb. A curved bis- 
toury can then be thrust well into the abscess and made to 
cut its way out toward the anus in the axis of the bowel." 

This is the plan used by him of laying open the smaller ab- 
scesses. To my mind, there are two objections to this method. 
First, the introduction of the finger into the rectum under 
these circumstances causes intense pain, against which the pa- 
tient vigorously protests. Second, he makes the cut toward 
the anus in the axis of the bowel. I think it a much better 
plan to make the cut parallel with the rectum in evacuating 
the pus, for the reason that it is very desirable that these 
external openings should not heal until all the pus has 
drained out and the discharge, which continues for several 
days, has been given free exit. When the cut has been made 
parallel across the folds, instead of toward the anus with the 
folds, the sinus is much more likely to remain open. My 
method of dealing with deep-seated abscesses is as follows : 
Getting the patient into a good light, I tell him what I am 
going to do. Then taking a knife with a good-sized blade— it 
is not necessary that it be curved— I plunge it into the cavity 
to its very depth, and as the knife is withdrawn I make an 
opening two or three sizes larger than that made in entering. 
My object in this is to get free drainage. I then introduce my 
finger or the end of the handle of the knife, and thoroughly 
break up all the loculi. I then syringe the cavity out freely 
with a solution of bichloride of mercury (1 to 5,000). Then a 
tent made of iodoform gauze is introduced into the cavity, 
just as much as it will hold. After the expiration of twelve 



188 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

hours, I withdraw the iodoform gauze and allow any accumu- 
lation to pour out freely. I have used the bichloride solution 
here first, because I believe it to be a good antiseptic and 
at the same time a good stimulant to the cavity. However, 
afterward I substitute another agent— viz., peroxide of hydro- 
gen. Of course, our great object in dealing with cavities of 
this kind is twofold : First, to stop suppuration ; second, to 
heal the diseased structure. For preventing suppuration, we 
have chiefly relied upon solutions of bichloride of mercury 
and carbolic acid. Every surgeon is well aware of the fact 
that dangers attend the use of carbolic acid in the treatment 
of suppurating diseases, and the too free use of the bichloride 
of mercury in large suppurating cavities might not only cause 
too much inflammatory action, but also produce a general effect 
upon the system which would be shown in ptyalism. We 
have in a strong solution of peroxide of hydrogen a substitute 
for these two without any of their attending dangers. Un- 
doubtedly the best preparation of this agent is Marchand's 
peroxide of hydrogen. His fifteen-volume solution will re- 
tain active germicidal power for many months, if kept tightly 
corked in a cold place. The price, too, is within the reach of 
all, being about seventy cents per pound. It can be used, of 
course, in any strength that the surgeon desires. March and 
has devised a hand atomizer and ozonizer for the purpose of 
using the agent in an easy manner. 

The abscess cavity is injected once a day with this agent, 
either pure or diluted with water, from three to ten parts, and 
each time the tent of iodoform gauze is pushed gently into 
the external opening, but so as not to fill the cavity. As the 
healing process goes on, a less amount of the gauze is used. 
If large rectal abscesses are treated in this manner, the num- 
ber of cases of fistulse will be greatly reduced. 

Fistulas in ano have been divided into four varieties: 1. 
Complete fistulse. 2. Blind external fistulas. 3. Blind inter- 
nal fistulse. 4. Horseshoe fistulse. 

I can not say that I like this division. Too much stress is 
put upon the varieties by many physicians. I allude more 



FISTULA IN ANO. 189 

especially to complete fistula? and the necessity of finding the 
internal opening. It is surprising to hear patients announce 
the fact that an operation has been refused them because 
the internal opening could not be found. It often occurs 
that patients say that the doctors have searched many times 
in vain for this internal opening, and at last have given it up 
and declined to operate. What this has to do with the opera- 
tion for fistula in ano I must confess I can not understand, 
and yet authors have taken great pains and teachers go to a 
great deal of trouble to explain how to find this opening. A 
very favorite plan is to inject the external opening with some 
colored substance, iodine or something else, and then have 
something on the inside of the bowel that it will discolor, and, 
when it is seen, they are able to say that an internal opening 
exists. Now, admitting that they are so desirous of finding 
this opening so that it may be included in the cut made for 
fistula, I would answer this argument by saying that if dur- 
ing the operation I introduce my grooved director and fail to 
find any internal opening, when one really exists, I push the 
instrument through the mucous membrane, then divide the 
tissues upon it, and search up the bowel from the cut, allow- 
ing the director to go as high as it will. Then, dividing again, 
we of course include any internal opening that might exist. 
Again, I would say to those who would introduce the director 
into a complete fistula, and allow it to pass through the in- 
ternal opening, then making a division of the tissues, that the 
operation for fistula is not complete unless they search higher 
up the mucous membrane from the bottom of the cut, because 
an additional little branch may run up in that direction. 

. Case.— Several weeks ago a gentleman came to me from a 
Northern city to be examined, he said, for fistula, remarking 
that several surgeons lately had him on the operating table 
under the effect of an ansesthetic, and, because they could 
not detect the internal opening, they did not operate upon 
him. I would not have believed this story except that I had 
had many patients to tell me, in substance, the same thing. 
I placed him on the table and discovered a very small exter> 



190 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXUKE. 

nal opening up in the perineum, which ran toward the bowel 
about one inch in depth. It did not go into the bowel. I 
said to him : " I do not care to examine you any further, but 
propose to operate on you whether I can find any internal 
opening or not." He consented, and I did the operation the 
next day. The probe passed down, while he was under chlo- 
roform, to the mucous membrane, and I pushed it into the 
bowel, and then, substituting a grooved director, I incised the 
tissues and finished the operation according to rules laid 
down. He made a good recovery. 

Case. — A physician living in Kentucky brought an official 
of his county down to me for an "opinion" in a case of 
fistula in ano. In my consultation room the physician told 
me that he had had this patient in this city once before to 
see a surgeon, and that he searched for a long while by many 
different methods to find the internal opening, but failed to 
do so, and no operation was done. He then remarked that, 
after going home, he had tried upon many occasions to pass 
the probe into the bowel, but could not. I replied to this 
statement of the case that my consultation would amount to 
very little, for I paid no attention to finding an internal open- 
ing of a fistula, if an external opening existed ; that that 
could be done when the operation was performed. The pa- 
tient was taken back home, and I learned afterward that the 
country physician operated on him. 

Now, the point I wish to emphasize is, that too much 
stress is put upon the finding of this internal opening, and 
that it is not necessary to worry one's self about finding it, 
for it amounts to nothing, so far as the operation is concerned, 
whether it is found or not. My practice in operating for 
fistula in ano is to make a cut through the main sinus at 
first, and then hunt out every single sinus that may exist. 
Upon this point, too, I want to be very emphatic. Van Bu- 
ren was inclined to think, especially in the first edition of his 
work, that the inflammatory condition that was set up by the 
division of the main sinus would eradicate or heal any re- 
maining branches. I am positive that this is not true. If a 



FISTULA IN ANO. 191 

fistula in ano has one main channel and six smaller branches, 
and if the main channel and five of the branches are divided 
in the operation, and the sixth branch is left, I am sure that 
in the majority of cases a good result would not obtain, from 
the fact that the sixth branch would not be closed. It must 
be remembered that these fistulous tracts are lined by hard 
cartilaginous material — the so-called " pyogenic" membrane. 
It has no vitality, is very tough, and will not heal unless 
freely divided at the bottom and the top or scraped out. Of 
course, the idea that this membrane was pyogenic was a mis- 
take, for pus is not a secretion, and this substance does not 
secrete at all. I recall a case that Allingham, Sr., detailed to 
me a number of years ago, which was about as follows : 

A lady of wealth, living on this side of the ocean, had her 
fistula operated on by a distinguished surgeon in this country, 
but noticed that after the wound had healed pus still dis- 
charged from the rectum. The surgeon did the second opera- 
tion on her, laying open the tissues in about the same place 
and manner ; and when the second healing took place she still 
noticed, months afterward, the same discharge of pus from 
the rectum. She then concluded to cross the ocean and con- 
sult Allingham. As is his most excellent custom, he carefully 
searched inside of the rectum for a cause of this condition of 
affairs, and he found, beginning at the end of what was the 
original cut for fistula, a small opening which ran up the 
gut about one inch. He introduced a small director into this 
channel and laid it open, after which the woman got well. 

Of course, it can be easily seen that the mistake the Amer- 
ican surgeon made was not to lay open the sinus that ran up 
the mucous membrane from the entrance of the internal fis- 
tula. I believe that it requires a more careful surgical opera- 
tion to cure a complicated fistula in ano than almost any 
other surgical disease. Even when we are the most careful 
and do the most cutting, tracing up every sinus and attend- 
ing to every detail and minutia of the operation, we find 
sometimes, when the healing process is complete, that the 
disease is not eradicated. It comes nearer to getting the 



192 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

surgeon into disrepute than to lose a case after an abdominal 
section. Another thing that I wish to impress is, that, as far 
as possible, the surgeon doing the operation should have the 
patient under observation until the healing process is accom- 
plished. If he leaves his cases in the hands of others to treat 
after the operation is done, he will have many cases of fail- 
ure to report. To show how far the patient can be neglected 
after this operation, I mention the following case : 

Case. — I was called to a small town in an adjoining State 
to do an operation for a very deep and complicated fistula. I 
did the operation under as much antiseptic precaution as I 
could, considering the circumstances, but during the operation 
a great deal of haemorrhage took place, particularly from the 
bottom of a very deep cut through and into the left buttock. 
A great amount of tissue was trimmed away and a space was 
left nearly large enough to admit my hand. I had an aseptic 
sponge with me, which I placed at the bottom of the wound, 
and packed absorbent cotton over it. Then placing a bandage, 
I left for the city. I was requested to come back to see the 
patient in about ten days. I did so, and was told that the 
wound had been carefully cleansed at the end of the third 
day, all dressing removed, and the injections used as directed. 
The man being large, the parts naturally fell pretty closely 
together when the dressings were removed. I took out the 
cotton which had been inserted that morning, but there was 
more welling up of pus than I liked to see, w T hich could 
hardly be explained. I was about to redress the wound when 
my finger detected something at the bottom which did not 
feel like granulating tissue. I introduced a long pair of 
dressing forceps and, catching hold of it, I withdrew what 
proved to be the sponge which I had placed in the bottom of 
the wound on the day I did the operation. I quickly threw 
it out of the window, that the patient might not see it, and it 
was explained by the doctor telling me that he had neglected 
to remove it, consequently it had been in the wound for ten 
days. Of course, this greatly retarded the healing process. 

I more and more believe that the good results in this opera- 



FISTULA IN ANO. . 193 

tion are due as much to the careful treatment of the wound as 
in the operation itself. Although I accept the divisions made 
herein of the varieties of fistula, I sometimes think that the 
term fistula in ano should be dropped. In the first place, 
fistula in this locality has very little to do, from an anatom- 
ical point of view, with the anus ; and, secondly, many fistulse 
that we meet in this neighborhood have no connection either 
with the rectum or the anus. There is a variety of this sort, 
although it is exceptional, which is sometimes met by the 
rectal surgeon. I allude to fistula that originates over the 
sacrum and extends either upward or downward, but, as far 
as the operation is concerned, it has nothing to do with the 
rectum, and yet falls within the domain of the rectal surgeon. 

Case. — Dr. K. sent for me a short time ago to see a Catho- 
lic priest who was suffering from fistulse. An examination 
revealed the fact that there were two external openings — one 
located over the sacrum, and one over the last lumbar vertebra. 
Introducing a probe into either one of these, it could be felt 
that the spine was crossed by the sinus or sinuses, but that 
they did not reach within several inches of the anus, and had 
no connection with it. An operation was done the next day, 
under chloroform, which consisted in laying open all the 
sinuses, trimming off all the edges, and scraping out thor- 
oughly the base of each tract. A very large and ugly wound 
was made. The case was taken charge of by his excellent 
physician, who was also a good surgeon, and a splendid 
recovery took place. 

I suppose my record book will show fifty such cases of 
fistulse located in this region, and yet under the general va- 
riety of fistulse in ano they are not classed at all. It must be 
understood that the same condition of affairs may exist in 
other locations around the rectum and yet not involve the 
rectum, as, for instance, in either buttock. It would be very 
bad surgery to push a director down into the rectum and ex- 
tend the cut through the same, under the idea that it was a 
fistula in ano, and that it had to be so operated upon ; and it 
may seem strange to say that this thing is ever done ; but I 

13 



194 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

know of a fact that it has occurred quite a number of times. 
To consider, then, the varieties : Complete fistula is said to be 
one where the sinus extends from an opening on the outside 
of the sphincter muscle through the mucous membrane into 
the rectum. The fistula is said to be a blind external one 
where there is an external opening without a corresponding 
internal opening. An internal fistula is where there is an 
internal opening and no corresponding external opening. 
The fourth variety has received the name of "horseshoe" 
from its resemblance to one, there being generally but a sin- 
gle opening into the bowel at the back part, while there may 
be two openings through the skin, one on either side. Fre- 
quently in this variety of fistula we have many branches run- 
ning off from the main branch, which makes a complicated 
condition of affairs, inasmuch as we have to consider the 
safety of the muscles in doing the operation. 

Complete Fistula. — It is said by most authors that this is the 
commonest form of fistula in ano, and yet if we would take the 
experience of physicians in locating the internal opening of a 
fistula, we would suppose that the external variety was the 
commonest. Of course we attribute this to the fact that it is 
very difficult to find the internal opening of a complete fistula. 
Some authors go so far as to say that all external fistulse have 
a corresponding internal opening, yet experience will teach 
that this is not the fact. As I have said, I do not believe 
in placing so much stress upon the finding of the internal 
opening, and I certainly would not abandon an operation for 
fistula because it could not be found. It is very well, how- 
ever, to study its situation. I take it that the formation of 
the original abscess is responsible for the establishment of 
both openings. As we have said, pus will burrow, and an 
abscess being a cavity filled with pus, it is very natural that 
in seeking an exit it should go toward the point that will 
offer the least resistance. Therefore the situation of the ab- 
scess has very much to do as to where this point of exit will 
occur. If the abscess is a marginal one, as the French say, it 
willbe very apt to open just within the verge of the anus 



FISTULA IN ANO. 195 

through the mucous membrane or externally through the 
skin on the outside of the sphincter. If it is an abscess 
located in the "superior pelvi-rectal space" above the le- 
vator ani muscle, it will open through the mucous membrane 
into the bowel proper. If it is, however, located in the ischio- 
rectal fossa, the pus makes its way to the surface through the 
space of least resistance, which is usually both toward the 
surface of the skin over the fossa and inward to the space 
between the two sphincter muscles. A physician who is 
called on to attend a rectal abscess should keep in mind 
these points from the fact that it is for the well-being of his 
patient at least to prevent the sequel, which would be fistula 
in ano. If left to itself, an abscess originating in the fossa 
would likely break internally ; but the physician, recogniz- 
ing that this is the most serious form of fistula, will, as has 
been recommended here, open the abscess externally, thereby 
preventing the breaking of the abscess into the bowel. It is 
a matter of some concern as to where this internal opening is 
located, on the supposition that it exists. Physicians are in 
the habit of searching too high up the bowel to find it. Its 
usual location is between the two sphincter muscles, and the 
reason for it is that the least power of resistance is offered 
here to the abscess's forming in the ischio-rectal fossa. An- 
other error that we fall into is that we suppose fistula in ano 
to be a narrow and close channel communicating from the 
outside with the inside of the bowel. Such fistulse as these 
are seldom found, but upon close inspection it will be noticed 
that not only diverging from the main sinus along its route 
are additional branch sinuses, but also at the end of the origi- 
nal sinus, which ends at the internal opening into the rectum, 
they may be found. A probe could be swept around under 
the mucous membrane for perhaps an inch. This will explain 
why the operation usually advised for fistula, which is the 
simple laying open of the main sinus, will not effect a cure. 
In making the examination for either variety of fistula it is 
very well to use the finger in helping out an opinion. For 
instance, if we see an external opening in the neighborhood 



196 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

of the anus, by placing the finger at this opening and run- 
ning along the route toward the bowel, if a fistulous sinus 
exists, it can be felt as a strong whip-cord or pipe-stem under 
the skin, or perhaps deeper in the tissues. If, however, this 
is not the route that is taken by the sinus, it can be detected 
in the same manner by tracing it out with the finger. When 
we have decided upon the line that the sinus takes, it is well 
now to introduce a probe into the external opening, and allow 
it to follow in the direction that the sinus takes. If it dips 
toward the bowel and stops at any particular point, by a gen- 
tle manipulation of the probe, or a dexterous move, it may 
pass farther on. After this is done, the forefinger of the right 
hand should be anointed with vaseline and inserted into the 
bowel. This will act as a guide and a firmer pressure can be 
made upon the probe, and it is very likely that the instrument 
would be felt just under the mucous membrane. If, after a 
little endeavor, it does not pass into the bowel, you should be 
content with your examination, being certain that, when the 
operation for fistula is performed, the internal opening will 
be found ; and, if not, the probe will be pushed through the 
mucous membrane and the operation made complete. I cer- 
tainly would prefer this method to that of injecting milk, 
iodine, etc., through the external opening, and then trying 
to observe by a speculum the point at which it flows into the 
bowel, for I consider this unnecessary. In cases where there 
are extensive fistulous tracts it is unnecessary to trace them 
at all, the only question being whether an operation is war- 
rantable, and this is to be determined by the existing com- 
plications or by the health of the patient ; as, for instance, 
where fistulous sinuses are the result of stricture of the rec- 
tum or perhaps cancer. 

Blind! External Fistula. — This I consider to be the least harm- 
ful of all varieties of fistula. It is supposed to be a tract 
that begins externally but has no internal communication. 
Therefore no portion of the contents of the bowel can enter 
it which would be possible in both internal fistula and the 
complete variety. It should be taken into consideration that 



FISTULA IN ANO. 19 7 

there is a vast deal of difference in cases of fistula in ano. 
I have tried to impress the fact that some fistulae are pro- 
gressive and some are non-progressive. It may depend entire- 
ly npon circumstances which variety we meet. If an abscess 
has been the result of any special diathesis, we can look for 
much burrowing of tissue, even if the abscess has resulted 
from trauma, and in a feeble individual we can expect the 
same thing. Locality has much to do with it. In superficial 
abscesses we expect very little trouble. In deep-seated ab- 
scesses we expect more, but whether it be an acute or a chron- 
ic abscess it should be determined by the physician in charge 
whether it is a progressive one or not. In this connection I 
beg to report two cases which will be mentioned in the same 
line. Two brothers consulted me in regard to a fistula in ano 
in the person of each. It was a very singular coincidence 
that the fistulse were very much alike in both persons. An 
external opening could be seen dorsally situated, about an 
inch and a half from the anus. In one the abscess had oc- 
curred about six years previous ; in the other, about eight 
years. There was scarcely any weeping from either one of 
them. I made an examination with the probe and found that 
there was no internal opening. The sinus felt to the finger as 
a hard cord underneath the skin. No pain or inconvenience 
was noticed. They said to me that it was a busy season with 
them, and that if I thought the operation could be deferred 
it would meet their plans best. After making up my mind 
that it was simply an external fistula, lined by a hard carti- 
laginous membrane, I said to them that there was no danger of 
much progress of the fistula, and that as they had stood it 
for six and eight years without any apparent trouble, they 
could stand it for a while longer. That has been a number 
of years ago, and, although I have seen the gentlemen a num- 
ber of times since, they have never alluded to their fistnlae. 

Therefore I say that we will frequently meet fistulous 
sinuses that are not attended with any danger even if they 
are left, and yet this would be poor advice to give in a gen- 
eral way. 



198 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

Case. — A young man consulted me for fistula, giving 
the history of an acute abscess several months before. He 
was advised to let it alone. But as he had noticed a rapid 
spread, as he expressed it, of the disease, he came to me for 
advice. Upon examination, I found a large, patulous, exter- 
nal opening, into which I could introduce my linger, and from 
which I could trace numerous sinuses. Although this young 
man was robust in appearance, I suspected that this fistula 
was tubercular in character and was rapidly extending. I 
advised him to have an operation done just as soon as pos- 
sible. He consented to this, and in doing it it was remarkable 
the amount of tissue that was involved. Sinuses were found 
running in different directions, which terminated in what ap- 
peared to be a cavity which drained itself through these chan- 
nels, located in the buttock. A very extensive operation had 
to be done for his relief. 

Another mistaken view that patients sometimes take, and 
are backed in it by the advice of the family physician, is to 
have this external opening healed. And here comes the ob- 
jection to the injection plan as applied to sinuses. I am sure 
that much more detriment is done to patients than good in 
following out any such advice. Charlatans are in the habit 
of applying some caustic to the external opening of fistulse 
and thereby causing them to heal over, and persuading the 
patient that he is cured of the disease. Now, in reality, he 
is made much worse by this procedure, for, if the external 
opening is closed, there being no internal opening to the fistu- 
la, the pus, serum, or what not, is confined in this channel, 
and it naturally seeks an exit ; consequently it burrows in 
different directions. If a case of this kind is watched while 
under any such treatment, at the end of several months it will 
be observed that there are a number of channels, whereas in 
the beginning there was only one. I have seen many of these 
cases that have come to me from the itinerants who have been 
under treatment, paid their money, and been discharged as 
cured ; and afterward, their trouble reappearing, they were 
referred to me for treatment. I always say to the patient 



FISTULA IN ANO. 199 

who has an external fistula, and because of circumstances 
can not be operated on, that he should make it a point to 
keep the sinus freely open, and in the case of traveling men 
especially, I provide them with a little probe that they them- 
selves can each day insert, thereby evacuating the contents 
of the sinus and preventing any accumulation within the 
channel. Persons may suffer from this variety of fistula and 
scarcely know it. They will tell you of the original abscess 
and that it healed, and, to their mind, they had entirely re- 
covered. Perhaps they will add that occasionally they have 
noticed a slight weeping at a certain point, but when you 
come to investigate you can not find the point at all. I have 
known cases of fistulse operated on where the original sinus 
had escaped notice entirely. The orifice is often so very small 
that it will escape even a rigid examination. A fold of skin 
may embrace it, or it may be found hidden under an external 
tag. A favorite site is along the perinseum, perhaps covered 
by the scrotum ; but, to avoid mistakes, a careful search 
should be made in every instance until the opening is found. 
Another mistake sometimes made by surgeons is to operate 
upon the channels that are easily discovered, which are in 
reality but branches of the main sinus, and yet this original 
tract is never touched at all, or, in other words, is over- 
looked. 

Case. — A gentleman from Texas had been under the ad- 
vice and treatment of an advertising physician for eleven 
months. During this time he had performed eight or ten 
different operations upon him. Although the doctor (?) had 
advertised that he never used the ligature, each operation 
that was done on this man was by the application of a 
silk ligature, which was verified by my examination of him 
afterward. He was seen on the street one day in a crippled 
condition by a worthy physician of this city, who had been 
an old schoolmate of his. In the conversation it was revealed 
that this man had been away from his home under treatment 
here for nearly a year, had been broken up in business at his 
home, and had despaired of ever getting well. He was ad- 



200 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

vised by the physician to leave the charlatan and seek my 
advice. When I examined him a very bad condition was 
observed. He had as many as five large and deep suppu- 
rating wounds around the rectum, caused by the cutting 
through of ligatures. Through two other sinuses the silk 
thread was still hanging. Upon a careful investigation of his 
case I detected, about two inches up the bowel, a large and 
angry-looking internal opening, which proved to be the origi- 
nal sinus in this case. I told him that I could not do any- 
thing looking to his relief unless he took an anaesthetic, and 
allowed me to do what I thought was proper. After consult- 
ing his physician friend he concluded to submit to my advice. 
After a little preparatory treatment he was put on the table 
for an operation. The first thing that was done was to lay 
open the main channel, which began in the rectum and ran 
out into the perinaeum, approaching the skin close to the 
scrotum. The wounds that had been made by the different 
ligatures were theu searched, and at the bottom of them sev- 
eral sinuses were found running in different directions. These 
were freely laid open. The edges of all the wounds were care- 
fully trimmed away, and the whole surface dressed according 
to antiseptic rules ; and at the end of three months this 
man was discharged cured, though a great deal of the scar 
tissue remained. Although the sphincter muscle was divided 
twice, he was afterward able to retain his faeces and to have 
his actions with comfort. He has paid me several visits since 
then, simply to show me in what excellent health he is. 

This case will go to show the necessity of seeking out every 
sinus that exists. It also goes to show that a very extensive 
cutting is sometimes necessary to effect a cure. 

Blind Internal Fistnlse. — These fistula? are of more importance 
than either of the other two kinds. If a fistula is complete, 
notwithstanding that it has an internal opening, it will drain 
itself to a certain degree at least of the faecal matter that 
passes into it from the bowel. If the fistula be an external 
one, it has no communication with the bowel, consequently 
nothing of this kind can pass into it. But if it be of the blind 



FISTULA IN ANO. 201 

internal variety, these discharges find a lodgment in the chan- 
nel with no point of escape, consequently it is being contin- 
ually irritated. It is no wonder, then, that patients complain 
more of this variety than of either of the other two. Some- 
times they will come to you saying, they believe that they 
are suffering from an impending abscess. Upon examina- 
tion, you will find a small indurated tumor in the tissues or 
just under the skin, and yet if you allow these patients to 
remain away from you for a few days, they will tell you that 
the tumor has all disappeared, and that they are suffering 
no further inconvenience. This condition of affairs has been 
brought about by the passage of liquid faeces through the 
channel, causing a slight inflammatory action, which has 
afterward subsided by the tumor's evacuating itself into the 
rectum if it contains pus ; but if it is inflammatory, it may be 
reabsorbed. It is quite a good idea in all such cases for the 
surgeon to make an incision into this small tumor, even if he 
has no history of an abscess, or can not detect the internal 
opening of the fistula. It is much better to have drainage 
externally than internally in all fistulse. Another point to 
which I would call attention is, that if the blind internal 
fistula has existed for any length of time, it is very apt to be 
complicated by additional branch fistula? ; therefore, during 
an operation, it should be remembered that they should be 
sought for. It is very bad practice to say to any patient 
suffering from either variety of fistula that his disease is a 
simple one, for an operation may reveal a very complicated 
condition of affairs. 

Horseshoe Fistula. — In this form of fistula the internal open- 
ing is usually found on the posterior wall of the bowel, and 
from this a tract leads into the ischio-rectal fossa, not on one 
side only but upon both. Therefore we have one opening into 
the bowel, and one through the skin on either side. But I 
have seen this variety of fistula go completely around the 
bowel without any internal opening at all. This form of 
fistula requires the most delicate operation to effect a cure. 
If you follow the channel in its entirety, you have really cut 



202 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

the tissues away from their attachment to the rectum proper, 
and therefore the sphincter muscle loses its function ; or, if 
you divide the sphincter muscle twice in the operation, which 
is the usual procedure, at one sitting, you destroy its function. 
The plan of operating will be described further on. 

The Relation of Eistula in Ano to Phthisis. — The belief among 
people generally, and with many physicians, is that fistula in 
ano has some direct connection with the lungs ; not with the 
diseased lung only, but also with it when it is in a perfectly 
healthy condition. This impression is widespread with pa- 
tients suffering from rectal disease, and the questions pro- 
pounded by them are sometimes really ludicrous. I have 
often been asked if the cure of piles would not result in con- 
sumption, and I have often had the objection preferred to 
curing a fistula that, if the discharge was stopped, it would go 
to the lungs ; and this, too, from persons of splendid physique 
and in perfect health, suffering likely from only a local sinus 
caused by the passage of a fish-bone. I find, too, that patients 
have been prejudiced against the operation for the cure of 
fistula by some physician who has warned them against it, 
lest they have consumption as the consequence: Of course, 
to the learned physician this would be pure nonsense ; yet 
the prejudice exists, and we are forced to use a sensible argu- 
ment to refute it. Among the old authors the idea was preva- 
lent that the discharge from the fistula in phthisical patients 
had a modifying influence upon the disease. There are many 
to-day who believe in this doctrine. This is commensurate 
with the belief in issues, setons, etc. From this early teach- 
ing many vagaries have resulted. Even the old writers, who 
knew but little pathology, did not believe, nor did they at- 
tempt to teach, that the curing of a fistula in a healthy person 
would result in phthisis, and it is very strange that in this 
day of research and pathological study there are men who 
will, by an ill-advised word, consign a person to a life of 
disgust, if not of torture, by advising against an operation 
which could do no possible harm, but, on the contrary, relieve 
him of a life of suffering. 



FISTULA IN ANO. 203 

Case. — Miss K. was brought to me by her family phy- 
sician suffering from an ugly condition of fistula in ano. He 
told me that he had had much trouble with the % abscess, not 
that it had caused much pain, but that it was so extensive 
and refused to break. He also stated that she was of a con- 
sumptive family, having just lost a sister with phthisis ; that 
other members of the family had died with it, and that this 
girl was suffering from an incipient tuberculosis of the lungs. 
She had lost considerable fiesh, had a bad cough and expec- 
torated freely, but her main complaint was about the fistula. 
The examination of the rectum revealed a characteristic, large, 
pouting opening of the sinus. The finger could be introduced 
into it and swept around in the tissues for a circumference of 
at least one inch. The skin covering this cavity was very 
flabby and of a bluish color. Under the circumstances I was 
a little chary about operating, and yet I realized the fact that 
this was a progressive condition of affairs, rapidly destructive 
to tissue, that the sinus would burrow in every conceivable 
way, and would not only undermine the sphincter muscles, 
but also break down the health of the patient. I therefore 
advised an operation. Incidentally I desire to say that in 
these cases the cough is a serious detriment. It is a well- 
known fact with surgeons who operate upon the rectum that 
the succussion from the cough is often so great as to prevent 
the healing of these wounds. Therefore, in operating upon 
the phthisical patient, the cough should be looked after. And 
another point that should be especially enjoined is, that this 
class of patients should not be confined to bed any longer 
than is absolutely necessary. I have frequently, upon the 
first week of confinement, advised them to get out of bed and 
take a walk, or in other ways gain some advantage from exer- 
cise and fresh air. This course will aid rather than deter the 
healing process. This young lady was etherized, taking it 
very kindly ; I divided the sinus running into the bowel, and 
then trimmed away all of the overlapping integument. The 
bottom of the sinus, or I should rather say the cavity, was 
freely scarified and dressed after the operation with bichlo- 



204 DISEASES OF THE RECTUM, ANUS.. AND SIGMOID FLEXURE. 

ride gauze. A stimulating course of local treatment was pur- 
sued, the patient allowed to eat freely of good, nutritious food, 
and to partake of milk punches through the day ; and, after 
five days' confinement in bed, to get out a portion of each day 
and exercise in the open air. Although a little slow, this 
wound healed perfectly, and the general health of my patient 
was rapidly improved. Although it has been two years since 
the operation was done, there has been no reappearance of the 
trouble. 

It behooves us, then, as physicians, having the care of 
these cases, to look into the doctrine taught by the old mas- 
ters in regard to this disease, and see if there be truth in it or 
not. It can not be gainsaid that consumptives are frequently 
the subjects of fistula. These fistulse may be dependent upon 
the tubercular diathesis, or they may not. A person having 
diseased lungs may be just as liable to the other causes of 
fistula — i. e., foreign bodies in the rectum, bruising, trauma, 
effect of cold, etc. — as persons who are perfectly healthy. Is 
a fistula in ano in the consumptive patient a thing to be de- 
sired, for the reason advanced by the older writers, namely, 
that the discharge of the fistula modifies the disease of the 
lungs ? If answered in the affirmative, I would ask if it would 
not be good surgery to produce an anal fistula in phthisical 
patients, if they were so unfortunate as not to have one ? The 
question at issue is, Shall we operate for fistula in ano in pa- 
tients suffering from phthisis % Before attempting to answer 
let us consider what some of the older writers have said on 
the subject. In 1837, when Busch wrote his work on disease 
of the rectum, he said: "It is very apparent that a great 
many fistulse depend on disease of the lungs ; therefore we 
should not operate on them, else their healing will give rise 
to the increase of the pulmonary disorder and curtail life." 
A few years before this Brodie had said: "No operation 
should be undertaken for fistula when phthisis is present, 
for one of two things will happen ; either the sinus, although 
laid open, will not heal, or otherwise it will heal as usual and 
the visceral disease will make more rapid progress, and the 



FISTULA IN ANO. 205 

patient will die sooner than he would have done had he not 
fallen into the surgeon's hands." Sir William Ferguson said 
that "the coincidence of fistula with disease of the lungs is 
often remarkable, and a surgeon would seldom be justified in 
interfering with a sinus under these circumstances." It seems 
that these really great men were given to theorizing in their 
day, as many are given to the same thing now. In these mat- 
ter-of-fact times we want to know if theory is borne out by 
clinical facts. When Busch tells us that it is very apparent 
that many fistulae depend on diseased lungs, and that we 
should not operate because the healing will give rise to in- 
creased pulmonary disorder, he should have established this 
saying by clinical facts, or his statement is good for nothing. 
When Brodie affirms that under the same circumstances the 
wounds will not heal, or if they should heal the patient would 
die sooner, he should have given us some statistics of opera- 
tions to prove it. The statement of Sir William Ferguson 
that we are not justified in interfering with the sinus, simply 
because the patient has a cavity in his lungs, is not substan- 
tiated by facts. Some of these writers say : " Don't operate, 
because the wound will not heal " ; others, that the wound will 
heal, and that this is the danger. Certain I am that if I oper- 
ate on any patient, under whatever circumstances, and the 
wound heals perfectly, I congratulate myself that I have 
done a good thing. The trouble in the consumptive patient 
is that the wounds are slow to heal, but not for the reasons 
usually given. But of this further on. Is there any degree 
of truth in the assertion made by these authorities that we 
should not operate on this class of patients ? Are their rea- 
sons predicated upon facts ? I imagine that this view has 
obtained credence principally because patients who have 
phthisis, complicated by fistula in ano, often die of the lung 
trouble ; and, if perchance an operation has been done for 
fistula, the blame has been laid at the surgeon's door, albeit 
that the life of the patient may have been prolonged and 
made comfortable rather than been shortened by the opera- 
tion. No good surgeon would risk his reputation by oper- 



206 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ating upon a patient who has rapid symptoms of advanced 
phthisis — as hectic, sweats, cough, emaciation, etc. — unless 
there was a strong demand for such operation. But that 
there are many cases of consumption made worse by an ex- 
isting fistula there can be no doubt. By curing the fistula 
the lung trouble will be benefited. There are several ques- 
tions that should be considered before operating upon the 
phthisical patient for fistula. 1. Will the wound heal ? 2. 
If the wound heals, will the patient be injured or benefited ? 

In answer to the first question, there are several reasons 
for supposing that the wound would refuse to heal : First, 
when the lung trouble has advanced to a degree of emacia- 
tion with cough, there is a bad nutrition of all the tissues of 
the body ; hence the tissues around the rectum are included. 
The blood-supply to the part is feeble, and the proper return 
of the same by the veins is impeded. Under these circum- 
stances the effort at repair would be poor. If cough exists, 
the succussion, as I have intimated, would materially prevent 
the healing process. A more serious reason than these, how- 
ever, is to be found in the condition of the parts operated 
on. The books are in the habit of giving three varieties of 
fistula — namely, external, internal, and complete — often for- 
getting to mention the different varieties of these three, and 
the operation is usually construed to be the introduction of a 
director and the division of the main tract. Any one who 
has operated many times for fistula in ano knows how er- 
roneous this is. As has been before stated, very often when 
one external opening presents itself, if a search is instituted, 
it will reveal many additional sinuses. Now, this is usually 
the case when fistula is found in the phthisical patient, not 
only many sinuses, but cavities of small caliber. If any of 
these escape notice, the wound does not heal because of the 
continual flow that is kept up. It would then become a ques- 
tion of importance whether the patient could bear that much 
cutting, especially if the sphincter muscle is involved. The 
surgeon alone is to decide. It has been an observation of 
mine that wounds upon the consumptive heal more readily 



FISTULA IN ANO. 207 

than is supposed. I do not refer here especially to fistulous 
wounds. The character of fistulse may be very different 
from those described. I have seen many plain, uncomplicated 
cases of fistula in people who had phthisis ; although, as a 
rule, the sinus is after the manner described. Then the char- 
acter of fistula is very different, and it is upon this fact more 
especially that I beg to differ from the learned men that I 
have quoted. Without making any distinction, they assert 
that the fistula must not be touched if the patient has phthi- 
sis. Patients are to be left under this general rule to bear 
their pain and the annoyance of a continual discharge, when 
they have fistula, perhaps of insignificant proportions, which 
could be easily cured. But those taking this side of the 
question do not have to go to the older authorities upon the 
subject to have their ideas confirmed. Gross said: "All 
attempts at a radical cure of fistula are inadmissible when 
there are serious organic lesions in other parts of the body, 
especially the lungs. In such cases we can not be too cau- 
tious, lest in arresting too suddenly a discharge, which has 
perhaps become habitual, we throw the onus en the more 
important organ and induce death prematurely." 

Erichsen inclined to the idea that a fistula may act as a 
derivative in these cases, but says that in the early stages of 
phthisis an operation improves the patient's condition, then 
adds that an issue should be established in the arm or the 
chest for a time. These two opinions lead us to consider the 
second question : If the wound heals, will the patient be in- 
jured or benefited thereby? We are to suppose, then, that 
the patient has vitality sufficient for the wound to heal. 
Does the healing advance the phthisis ? Both from a theoret- 
ical view and a practical demonstration, I would answer in 
the negative. I have operated many times for fistula in 
phthisical patients, and I have never had cause to regret it. 
Just as often, for reasons other than those given by these au- 
thors, I refused to operate. Is a fistula in ano a derivative 
for the lungs, as Erichsen intimates ? If the principle of the 
doctrine of derivatives is correct — which I do not admit — this 



208 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

appears to me to be most far-fetched of all. The fistula in 
the rectum can have no bearing on the lung in a derivative 
way. The distance is too great, and there is no anatomical 
connection— arterial, venous, capillary, or nervous — which 
could account for it. Hence I can not see what could be 
derived by it. The fistulous sinuses and cavities which exist 
as the result of the phthisical habit are simply the breaking 
down of tissue or the rapid degeneration of it. Therefore 
this is not only destructive, but is also a great waste. Then 
are we to suppose that, by keeping up the waste and allow- 
ing the degeneration of tissue to go on, we benefit an already 
enfeebled lung, or, by stopping this waste, we are, as Gross 
says, to hurry on the lung disease? We can not subscribe 
to this. If there was an overabundance of some destructive 
material in the body, whose presence was working harm, and 
by a derivative we could draw it away or waste it, then the 
proposition would appear reasonable ; but here we are draw- 
ing from an already impoverished body. Add to this the 
mental anxiety that exists, besides the loathsome disease, and 
I am constrained to say that in many selected cases the opera- 
tion should be done, and that I differ radically from the views 
herein quoted against the operation. 1. In incipient phthisis 
the operation is always justifiable, other things being equal. 
2. In the rapid progressive fistula an operation should often 
be done to save tissue and prevent serious consequences. 3. 
If great cough exists, it militates against the operation. 



CHAPTER IX. 

TREATMENT OF FISTULA IN ANO. 

There can be no doubt that spontaneous cures take place 
of fistula in ano, sometimes without any interference at 
all, but usually as the result of a very simple examination 
with the probe. I am satisfied that I have seen at least a 
dozen such cases in my practice. Again, one will be surprised, 
in dealing with large rectal abscesses, where everything points 
to the fact that they will be followed by fistula in ano, when 
all symptoms disappear and the abscess heals without trouble, 
leaving no trace whatever. 

The first question that a patient with fistula in ano is likely 
to ask the surgeon is whether it can not be cured without an 
operation. To meet the whims of patients, more than any- 
thing else, I imagine that the injection plan for fistula or the 
local application of caustics was first introduced. Of course 
the objective point in this treatment is to destroy the so-called 
" pyogenic " membrane by means of the escharotics. Grant- 
ing that it could be done, the point must be conceded that it 
is not only slower than the knife operation, but it is equally 
as painful. Again, injecting into the sinuses an escharotic 
that will destroy the tissue which lines their internal surface, 
might incite sufficient inflammatory action to cause an ab- 
scess. This plan is a very old one, and the agents used were 
iodine, nitrate of silver, nitric acid, and in later years car- 
bolic acid. With modern surgeons the plan is nearly obso- 
lete. We find in the books, however, a reference to it, and 
in some few cases it might do very well to try it. Allingham 
thinks well of dilating the sphincters, the application of car- 
bolic acid, and the introduction of the bone stud to keep the 

14 



210 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

wound from healing. Agnew, in his book on the Treatment 
of Haemorrhoids and other Non-malignant Rectal Diseases, 
says: "The treatment by injection, sometimes classified as 
the 'non-operative method,' has been so successful in the 
hands of many that it is stoutly affirmed that any case cura- 
ble by the usual heroic methods is equally curable by this 
method. Different preparations have been used, chief of all 
being carbolic acid, ranging in strength from fifty per cent 
up. In adopting the carbolic-acid treatment, probably the 
better way, after preparing the sinus, will be to use an eighty- 
per-cent solution the first time, and subsequently a fifty -per- 
cent solution, protecting the parts from excoriation by any 
suitable unguent and absorbent cotton. Hot -water com- 
presses to relieve pain, eucalyptol, calendula, campho-phe- 
nique, etc., in the interim. Judgment will be required in not 
making too many irritant applications and granulation thus 
hindered for want of rest. ... As a preliminary step the ex- 
ternal orifice should be well dilated with a laminaria tent or 
other appropriate means, and a fistulous tract explored with 
a common probe and thoroughly cleansed with hot water in- 
troduced through a flexible silver cannula. The cannula is 
also used for the injection of a five- or ten-per-cent solution of 
cocaine to obtund the sensibility before the injection of the 
acid. After the fistula has been suitably prepared for the 
reception of the acid, the silver cannula, attached to a hypo- 
dermic syringe charged with the acid, is passed up into the 
tract, the finger inserted into the rectum, and the end held 
over the internal opening, if the fistula be complete, to prevent 
the acid escaping into the bowel. The cannula is then slowly 
withdrawn, and the acid gently forced out of the syringe at 
the same time. The residual acid is allowed to remain in the 
fistulous tract for a few moments. The tract is then pressed 
with the finger, and syringed out with a weak solution of acetic 
acid and injected with oil. Once in two or three weeks is 
sufficient to repeat the injection of the carbolic acid should 
more than one application be required. Often one application 
of a strong solution will be found sufficient to effect a cure." 



TREATMENT OF FISTULA IN ANO. 211 

I have quoted Agnew in detail, first, for giving those of 
my readers who desire to try the plan an opportunity to do 
so ; and, second, to dissent from the opinion that this is even 
a good method in any variety of fistula when compared with 
the other accepted plans. As I have mentioned, no proper 
gauge can be pat upon the agent used. If too little, not suffi- 
cient inflammation is excited ; and, consequently, no good is 
accomplished. If too much inflammation is the result, great 
damage may be done. Therefore, concurring in the idea that 
if this tough lining could be destroyed without danger to the 
surrounding tissues, there might be a plan devised by which 
it could be done, in 1885 I read a paper before the Kentucky 
State Medical Society, suggesting what I was pleased to call 
"A New Operation for Fistula in Ano." It was described in 
the following words : " Taking the ordinary exploring probe, 
it is inserted into the external orifice of the fistula to deter- 
mine, if possible, that only one sinus exists. Being satisfied 
of this fact, I then take a long, slender laminaria tent, and 
push it gently into the fistulous sinus to the fullest extent it 
will go. This is allowed to remain for several hours, keeping 
the patient under observation during the interim, at the end 
of which time it is withdrawn. The procedure causes but lit- 
tle if any pain. The laminaria tent is preferable to a sponge, 
for the reasons that it is easier of introduction and furnishes 
its own moisture, which assists in its withdrawal. After this 
dilatation I take the smallest urethrotome, having a very small 
point ; closing the instrument tightly, it is pushed gently 
into the sinus as far as it will go, and then by the aid of the 
screw attachment I dilate the sinus. When this is done, the 
turning of the screw at the side of the instrument will cause 
the concealed knife to protrude at the distal end according 
to the measurement desired. The instrument is then carefully 
withdrawn, cutting through the wall of the sinus throughout 
its whole length. The cut, as will be perceived, has been 
made subcutaneously, and the pain is insignificant. What 
haemorrhage takes place is easily controlled by pressure. In 
several instances I have turned the instrument and reinserted 



212 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

it, practicing the same procedure on the opposite side at one 
sitting. If this is not thought advisable, the patient is allowed 
to go for several days before repeating the operation, which is 
to include the other side. The advantages that I claim for 
the operation are, viz. : Over the injection plan it must take 
precedence for the reason, as above stated, that the injection 
of any agent that is commonly used for such purpose does 
not accomplish what is desired, and is attended with danger. 
With this instrument both the top and the bottom or each 
side, if necessary, can be cut through, thereby insuring a 
good granulating surface, and this too without pain. Over 
the ligature, either elastic or non elastic, it possesses the ad- 
vantage of cutting through both top and bottom or each side 
of this thick membranous sinus, while the ligature can not 
possibly go through any portion but the top of the sinus as 
it cuts its way out, leaving, of course, a callous bottom, which 
in many cases would refuse to heal, it being a positive rule in 
surgery, in the operation for fistula in ano, that the bottom of 
all these tracts must be divided to insure a cure. Salmon 
used to say, after he divided a fistulous tract, "Now I will 
make the back cut, which will divide the bottom of the 
sinus," recognizing, as he did, that unless this was done he 
would likely not get a good result. Again, in using the liga- 
ture, the sphincter muscle or muscles must, of necessity, be 
cut through by the ligature if the internal opening is above 
them. In the operation with the instrument I suggest, the 
muscle is not divided or interfered with. Over the ordinary 
operation with the knife it can be claimed — 1. That this oper- 
ation dissipates all horror in those patients who dread the 
knife. 2. That excessive haemorrhage is avoided. 3. The 
sphincter muscles are not cut. 4. The patient is not confined 
to bed or taken from business. 5. The tissues are not in- 
cluded in the operation. 

In the majority of cases that I have treated by this 
method I have done so without the patient's knowing that 
anything in the nature of an operation had been performed. 
Exhibiting the instrument to them — the knife being con- 



Plate III 




OPERATION FOR FISTULA IN ANO BY MATHEWS'S FISTULOTOME. 



TREATMENT OF FISTULA IN ANO. 



213 



1 



cealed within it — they have never known other than that it 
was a probe. If I find, after waiting a few days, that a suffi- 
cient depth was not reached, the instrument is again inserted 
and the same procedure gone through with. The patient is 
kept under observation a sufficient length of time to be 
assured of a perfect cure. One point should be strictly 
watched, and that is that the external opening is not 
allowed to heal before the sinus does. Where pus 
cavities are found, or additional sinuses exist, of 
course this operation is not advised, but in the se- 
lected cases mentioned I am sure that the advan- 
tages claimed for it will be realized. A score of 
cases in my practice attest its value. I enocuntered 
many disadvantages in operating upon the fistulous 
tract with the urethrotome : 1. It was too large to 
enter the orifice of the sinus, so recourse was had to 
the laminaria tent. 2. It only cut upon one side, 
hence required a second introduction to effect a 
division of both the top and bottom of the mem- 
brane. To meet these difficulties, I had my instru- 
ment maker make for me a modest little instrument 
which, for lack of a better name, I call a fistulotome. 
By reference to the cut it will be seen that it is 
very small, being but little longer or larger than a 
good-sized probe. It has within it two concealed 
knives. It is probe-pointed and easy of introduc- 
tion. In the end is an eyelet, which I sometimes 
thread with a filiform bougie, the object being for 
it to search out and enter any small branch that may 
exist when the instrument is pushed to the very bot- 
tom by the screw arrangement at the distal end. 
Both knives are uncovered at the same time. They 
are of sufficient length to cut entirely through the indurated 
membrane as the instrument is withdrawn, the plan being to 
insert the fistulotome as far into the sinus as possible, then 
uncover the knives by the screw attachment at the end. In a 
few cases I have injected muriate of cocaine ; then done the 




214 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

operation. However, I have never seen that it did nmch good. 
A better plan wonld be to inject the cocaine subcutaneously 
alongside the tract. There is so little pain accompanying the 
operation that I seldom nse this agent. 

Case I.— Mr. B., a mechanic, referred by Dr. Turner 
Anderson. After an extensive fistula, with a number of 
branches, had been laid open, with all the precautions as to 
trimming the edges, dividing the bottom of sinuses, etc., the 
wound healed perfectly. He came to my office a few weeks 
after he was discharged and stated that there was just a drop 
of something that caused a moisture about the wound. 
Upon examination, I found a small orifice, located just where 
the external cut was begun in the operation. Introducing a 
probe, I found that it entered, fully six inches, a superficial 
sinus that ran backward and not toward the rectum, and I 
had evidently overlooked it in the operation. While he was 
on the examining table in Sims's position I introduced my 
fistulotome, uncovered the knives at the end of the sinus, and 
the instrument was slowly and firmly withdrawn. As the 
knives approached the external orifice I quickly pulled it 
through the skin. A little bleeding occurred at the time and 
some soreness was complained of during the week, but at the 
end of ten days he came back and I could not discover the 
sinus at all. I watched the case until I was satisfied that 
there was no recurrence. 

Case II. — A woman reported at my clinic at the Ken- 
tucky School of Medicine with a fistula in ano, having an 
external opening about three inches to the left side of the 
anus. A probe revealed the fact that it communicated with 
the bowel, the depth of tissue being about half an inch. 
One of the surgical staff was allowed to do the operation. I 
did not notice him carefully, but I am satisfied that he simply 
made the division usually recommended, which was by intro- 
ducing a grooved director through the sinus into the bowel, 
and then dividing the tissues upon it, neglecting to make the 
back cut according to Salmon. The wound healed nicely. 
She reported back to the clinic, and, to all appearances, the 



TREATMENT OF FISTULA IN ANO. 215 

parts were in good condition ; but while she was on the table 
I took a delicate probe and searched the route of the sinus, 
and found, at the very beginning of it, that the probe went 
into the bowel, evidently through the same old tract. My 
idea was that the tough lining, being left at the bottom, the 
wound simply closed over it, leaving the channel. This case 
illustrates the fact that, in using the elastic ligature, which 
only divides the top of the sinus, this same result might have 
been obtained. I took my fistulotome and pushed it through 
this tract until I could feel it upon my finger, which I had 
inserted into the rectum. I then uncovered the knives, 
pulled the instrument out, and, in cutting its way, it divided 
the bottom as well as the top of the sinus. The woman was 
well within one week's time, and no probe could be intro- 
duced. 

I could cite a number of other cases that have been cured 
by this little instrument, but will make these two suffice. I 
want to be explicit in saying that the cases in which the fistu- 
lotome will prove of service are limited, and yet I see for it 
as wide a field as that for the ligature, either elastic or non- 
elastic. I want to put myself on record, too, that the cutting 
operation, as usually practiced — which is to divide all the 
tissues upon the director, trim the edges, cut through the 
bottom, and lay open every additional sinus — is the one to be 
preferred in the majority of cases for fistula in ano. It is the 
means par excellence for the treatment of this disease, and I 
might add that from time immemorial the laity has fought 
against it. Recognizing this prejudice, the charlatan has 
been ever ready to play to it, and has, in his pretentious and 
deceitful way, increased this prejudice. I believe that every 
surgeon who is in the habit of operating for this trouble will 
agree to the statement that it is impossible to cure the larger 
proportion of fistula with on t the cutting operation. I can safely 
say that when any other method — such as caustics, ligatures, 
etc. — is brought into comparison with the knife as an agent 
of cure of any surgical affection, the preference must be given 
the knife. It has always been a mystery to the profession why 



216 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

sensible people would consent to have tumors, etc., burned 
out by degrees with the caustic, hot iron, etc., in preference to 
their rapid extirpation with the knife. It is the story of the 
dog's tail being cut off piecemeal to avoid giving it pain. 
It might be said that we of the profession too often succumb 
to the w^hims and caprices of patients, thereby allowing them 
to dictate the means of cure. Therefore, in bringing before 
the profession this fistulotome, I simply ask a fair trial of it, 
not as a substitute for the operation by the knife, but as a 
means of curing a few selected cases that may be met with in 
the hands of any surgeon. Andrews, in his book on Rectal and 
Anal Surgery, kindly says: "An excellent regular surgeon, 
Dr. Mathews, of Louisville, has systematized this latter plan 
and made it more energetic. He dilates the external part of 
the fistula with a laminaria tent (and then with a fistulotome 
scarifies the interior), repeating the operation as often as is 
needful. It is demonstrated by Dr. Mathews on the one 
hand, and by the experiments of the quacks on the other, 
that by controlling these two conditions — viz. : (1) the un- 
favorable effect of the undrained septic fluid within the sac ; 
(2) the tightness of the external opening which prevents free 
drainage and keeps the sac distended with this putrid pus — 
many cases will heal spontaneously." Agnew says in his book, 
from which I have taken occasion to quote several times : 
' ' The fistulotome, shown in Fig. 24, is a contrivance which is 
perhaps destined to take the lead in the treatment of fistula 
generally. It is constructed that the fine cutting blades close 
on themselves, while the instrument, which is flexible and 
probe-pointed, is being introduced, but immediately open on 
withdrawal, and thus catch up and cut through the fistulous 
membrane. Who the inventor of this clever device is I have 
been unable to ascertain, having seen the invention claimed 
by three different physicians, one of whom speaks of curing 
seventy-six per cent of all cases treated by one operation — that 
is, by drawing the fistulotome through the tract once. Cases 
of long standing require that the instrument should be turned 
at right angles and drawn through the second time, and pos- 



TREATMENT OF FISTULA IN ANO. 217 

sibly repeated later on, and a tenotome employed to scarify 
any remaining indolent sinus." 

I have taken occasion herein to quote from the report that 
I made to the Kentucky State Medical Society in 1885, and I 
at least thought at that time that I was the originator of the 
plan. I have had no reason since to think that I was mistaken. 
It will be observed that at that time I was forced to use the 
small urethrotome, because I had never heard of any two- 
bladed instrument that had been devised especially for nse 
in fistula in ano. The gentleman that claims to cure seventy- 
six per cent of his cases of fistula with such an instrument 
certainly has a better instrument than the one that I have de- 
vised, or his successes have far overbalanced mine. But, for 
the reasons that I have already given, I am satisfied that with 
any instrument of the kind the cures would be very limited, 
outside of the character of sinus mentioned. 

Several years ago Dr. Frederick Lange suggested the ad- 
visability of treating fistula by excision of the entire fistulous 
tract, the raw sur- 
faces being brought 

together with sut- g ^ 

ures, with a view of 
securing healing by 

n , . , , • T _ Bush's needle-holder. 

first intention. I can 

not do better than quote his own report : "I described a cer- 
tain method, but my experience at that time was derived from 
a few operations, the results of which were only partly success- 
ful, though encouraging. The first operation was performed 
two years ago upon a lady who had a deep-seated fistula, the 
internal opening of which was situated two or three inches 
above the sphincter. She was perfectly cured in two weeks. 
Since then I have had about a dozen cases in which the extent 
of the lesion and the gravity of the operation varied, the re- 
sults being as follows : In four cases primary union occurred 
without suppuration. In three, a similar result was obtained 
with but slight suppuration. In four, the wound healed by 
granulation in a shorter time than it would have done after one 



218 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXUBE. 

of the old operations. In one instance I did not sew up the 
wound at all on account of inflammatory infiltration of the 
edges. In another, that of a gentleman whom I had treated 
during the acute stage of a very extensive gangrenous peri- 
proctitis, there was so much cicatricial tissue that I did not 
venture to excise at all for fear of removing so much of the 
muscle that incontinence might result. This patient has still 



Needles in handle. 

an internal fistula which causes no inconvenience except a 
slight discharge. My technique has been essentially the same 
as that described by me before— viz. : excision of the entire 
fistulous tract, together with all the lateral sinuses, such as 
not infrequently exist in the cellulo-adipose tissue above the 
sphincters, and union of the deep tissues by means of buried 
sutures of iodoform catgut, as well as accurate adaptation of 
the edges of the mucous membrane. The field of operation is 
constantly irrigated with boro-salicylic solution. The edges 
of the integument I prefer to unite by only a few sutures in 
order to allow drainage of the first secretion. Opium is ad- 
ministered daring the first two days. After the second day 
the bowels are moved easily with injections, a sitz-bath being 
used after defecation. I performed this operation only once 
in a case of fistula of tubercular origin, the result being per- 
fect. There was a large shallow sinus which did not commu- 
nicate with the rectum, a condition which in my experience is 
not infrequent in tuberculous fistula. In the Medical Record 
of June, 1886, Dr. Stephen Smith published a paper on this 
subject, in which he stated that in 1879 he conceived the idea 
of treating fistula in this manner after reading in Dr. Emmet's 
book a description of that gentleman's plastic operation upon 
the perinseum. At that time Dr. Smith excised the granulat- 
ing surface of a fistula that had been operated on unsuccess- 
fully six months before. Consequently that operation was 
scarcely applied to a fistula proper. He does not state just 
when he adopted the method described by him, but if it was 



TREATMENT OF FISTULA IN ANO. 219 

immediately after the operation above mentioned, he was 
probably the first surgeon to practice it. I take the liberty 
of claiming priority in my description of the details of the 
operation, and especially the use of antiseptic precautions, 
which differs in no essential feature from that given by him." 

I take this amount of space to devote to this operation 
simply that justice may be done Dr. Lange, as I have seen it 
stated several times that some surgeon in Berlin claims pri- 
ority in this operation. I have quoted from the proceedings 
of the New York Surgical Society, at its meetings of January 
12 and 26, 1887, and it will be noticed from Dr. Lange's re- 
port that he says the first operation was performed two years 
before, which would be in 1885. In a paper read before the 
Mississippi Valley Medical Association, in 1889, I took occa- 
sion to call the attention of that body to Dr. Lange's opera- 
tion, and reported three successful operations done by my- 
self, according to his plan. Of course, there are many cases 
of fistula in ano which could not be successfully treated in 
this manner. It is so often the case that such an amount of 
diseased tissue has to be cut away to establish the healing 
process that it is impossible to bring the edges in apposition ; 
but where such a thing can be done, after the bottom of the 
sinus or sinuses is divided or scraped, and especially if strict 
antiseptic precautions are practiced, this operation is to be 
advised. We all know how long and tedious it is for the 
healing process to take place by granulation in these cases. 
Therefore I am inclined to think exceedingly well of the 
operation as suggested by Dr. Lange. 

The Operation for Fistula in Ano by the Knife. — There are but 
two other operations looking to the cure of fistula in ano 
that are worthy of consideration— viz., the elastic ligature 
and the knife. I have already stated that when these two 
methods are contrasted I much prefer the latter, but I wish 
first to call attention to the fact that the description given of 
the operation by the knife, by the majority of the general 
surgeons who have written about it, is not only incomplete 
but very misleading. Hamilton, in referring to the operation 



220 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

in his most excellent book on the Principles and Practice 
of Surgery, says : "The probe, or somewhat flexible grooved 
director, being now thrust into the rectum and brought out at 
the anus, the operation is completed by dividing the interme- 
diate tissues. Having cut the sphincter, it only remains to 
lay a small piece of lint between the margins of the wound 
and place the patient in bed." 

To illustrate how erroneous this advice is, allow me to cite 
a case : If an abscess in the ischio-rectal fossa has left a 
sinus which runs directly into the bowel, and from this a 
branch fistula runs out into the perinseum, and another di- 
verges from the main channel into the buttock, no such 
operation as is described by Hamilton would effect a cure. 
It is the smallest part of the operation to lay open the tissues 
which lie over the main sinus. How often it is that the sur- 
geon is disappointed in the wound's refusing to heal after an 
operation for fistula, and an investigation reveals that it is 
due to a small sinus or pocket that has been overlooked ! I 
am sure, after a long experience in dealing with this opera- 
tion, that in the majority of cases operated upon, if a single 
sinus is left, a good result will not be obtained. In other 
words, the inflammation excited will not be sufficient to 
eradicate the branch fistula. The flaps or thin edges of the 
wound alone, if left, would prevent good union. 

Case. — Mr. L. F. S. had submitted himself for treatment 
to an advertiser who claimed not to use the knife, caustic, or 
ligature in the cure of fistula. He had been under constant 
treatment for several months when he discharged his sur- 
geon (?) and came to me. Upon examination, I found that a 
number of cuts had been made, if not with a knife, certainly 
with the ligature, and that they showed no disposition to 
heal. The edges of the wounds fell into the cut surfaces and 
were a source of great irritation. I discovered in the peri- 
neum an indurated sinus, which proved to be the oldest, or 
the original one, but had been overlooked by the gentleman 
who had him in charge. The patient was prepared for the 
operation, put under chloroform, this sinus divided, all the 



TREATMENT OF FISTULA IN ANO. 221 

edges were trimmed thoroughly, and the wounds dressed 
antiseptically. He made an uninterrupted recovery and was 
discharged in a short time. 

This case clearly demonstrates two propositions : one, that 
if additional sinuses are left, a cure will not be effected ; 
two, that anything less than a free cutting operation would 
have failed to cure. Before doing an operation for fistula in 
ano by the knife, it is necessary to give the patient some 
special treatment. We will consider, first, that the trouble 
exists in the otherwise healthy individual. In this, as in all 
other surgical operations, the alimentary canal should be 
thoroughly cleansed by the administration of a free cathartic 
or aperient the day before the operation. The eveniug pre- 
ceding the operation he should be instructed to take a pur- 
gative pill, not an aperient. The preference is given to the 
pill for the reason that only one, or perhaps two, actions will 
result, whereas in the aperient a loose condition of the bow- 
els exists and they will, perhaps, move during the operation. 
If the patient be accustomed to drinking alcoholic or malt 
liquors, it is quite a good idea to administer, a day or two 
before operating, a calomel pill. The evening before, he 
should be directed to take a hot bath. On the morning of 
the operation he should do without his breakfast, except 
perhaps a glass of milk or coffee, and be directed to take 
another bath, after which he is to put on clean linen and he 
is ready for the operating room, after having his bowels 
cleared by an enema of hot water. The parts are then shaved 
and washed thoroughly with a bichloride-of-mercury solution 
(1 to 3,000). He is then anaesthetized, when the sphincter 
muscle is thoroughly distended with a speculum and the rec- 
tum is syringed out with the bichloride solution. Consider- 
ing now that the patient is ready to proceed with, he should 
be placed in proper position. After trying the different ones 
suggested by the authors, I have long since concluded that 
on the left side, with the knees well drawn up, the left arm 
being pulled behind the patient, is the best. The instruments 
necessary for the operation are one tenaculum forceps, two 



222 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

rectal probes, one four-pronged forceps, one curved bistoury, 
three grooved directors varying in size, one pair of stout 
scissors, and one straight, heavy knife. Frequently we have 
not the number of assistants that we desire, and for this rea- 
son I devised a special forceps or clamp, which has already 




Rectal probes. 

been described under the head of the Treatment of Hemor- 
rhoids, which consists of four prongs instead of three, and is 
made to lock. By catching the tissues, they can be pushed 
aside, still in position, without the aid of an assistant hold- 
ing them. 

In a bowl on the table are the sponges in the bichloride 
solution (1 to -5, 000). I much prefer the sponge made of sur- 
geon's cotton, wrapped and sewed in antiseptic gauze, to the 
ordinary sponge. I am in the habit of throwing them away 
after the operation, thereby saving the necessity and trouble 
of disinfecting the sponge. The instruments are in the pan 
of carbolized hot water. The attendants as well as the opera- 
tor have been made aseptic. 

Method. — Supposing the case to be one of the external 
variety, the grooved director is inserted into the orifice pre- 




Grooved director. 

senting, and with gentle pressure allowed to seek its way as 
far as it will go. It will often be noticed that these tracts 
are tortuous and not straight. This should not confuse the 
operator, but after the director has gone as far as it will, with 
gentle pressure, the forefinger of the right hand should be 
anointed with pure vaseline, drawn from tubes, and inserted 



TREATMENT OF FISTULA IN ANO. 223 

into the rectum. The end of the director will likely be felt 
encroaching upon the mucous membrane. It is very well to 
manipulate it and see if it can not be made to find the inter- 
nal opening if the finger has failed to do so. I have seen 
surgeons conf used by the fact that it could not be detected, 



Gowlland's director. 

and consequently the director would not go into the bowel. 
This confusion, however, is unnecessary, because in the event 
of its refusal to pass through, sufficient force should be used 
on the director to push through the mucous membrane. 
Then it is caught by the forefinger, and, while being pushed 
by the left hand, is guided by the finger out at the anus. 
It can be now held in position, a sharp bistoury is placed in 
the groove of the director on the outside, and all the tissues 
remaining upon it divided. The irrigator, containing a solu- 
tion of l-to-5,000 bichloride of mercury, being ready, a stream 
is now to be played over the wound, and a sponge is used to 
wipe away the blood. A probe should then be taken and run 
along the route of the cut, and it will, very likely, run into 
an additional sinus from the main tract. It should then 
be withdrawn, and a grooved director, of a smaller size than 
the one just used, should be inserted, when with the knife 
it is also laid open ; nor should we be content after find- 
ing this additional sinus, for a further search may reveal 
several more, and with their detection they should be laid 
open. Another point that requires some attention is the 
investigation of the beginning of the original sinus on the 
outside. It will frequently be observed that, for a line or 
two at least, the skin is undermined. The knife should be 
drawn across it. One of the most important steps in the 
operation is the trimming of the edges. If we neglect this, 
a bad result will frequently be met. I am in the habit of 
trimming the edges of the wound even if there are no flaps. 
It is well recognized that these wounds are to heal by granu- 



224 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

lation, and this trimming aids it. The irregularity of the 
tissues, whether flaps or not, should be trimmed away. It 
will be often observed that a portion of the tissue is callous 
and our division of the sinuses has left ridges in it. This 
should be caught up with the pronged forceps and cut out 
with a pair of curved scissors. I frequently excise the whole 
bottom of the wound in this manner, and I am sure that it 
has aided much in the healing process. Some recommend 
the scraping out of these sinuses after the cut has been made. 
I have never been satisfied with that method of dealing with 
them. It will be found much better to treat them in the 
manner that I have suggested. 

The description of the operation that has been given deals 
with the external or complete variety of fistula. The opera- 
tion for an internal sinus, running toward the surface and 
having no external opening, is a more difficult thing to do. 
The difficulty lies in finding the internal opening and intro- 
ducing a director into it. One would think, from reading the 
descriptions in the books, that it was quite an easy matter to 
detect this opening. But the surgeon who has' operated often 
understands that it is a very difficult thing to do. If an ocu- 
lar inspection is made by means of a speculum, the mucous 
membrane is so put upon the stretch that it obliterates the 
internal opening, and if we use the finger as a guide there is 
nothing positive evidenced to the feel. Sometimes a lump on 
the outside can be seen and felt, which would indicate that 
it was the terminus of the internal fistula. If this is the case, 
an incision into it will reveal the fact, but in the majority of 
cases this is not shown. Indeed, I am of the opinion that 
fistula? of the internal variety usually run around or up the 
mucous membrane, and do not often extend out into the tis- 
sues unless the sinus or cavity is the result of a special di- 
athesis — as, for instance, tubercular. In this case the aperture 
is usually very large, and by inserting the finger into the rec- 
tum it will dip very readily into the opening. The operation 
consists in bending a flexible grooved director in the shape 
of a hook, and introducing it into the rectum upon the finger 



Plate IV. 




TREATMENT OF FISTULA IN ANO. 225 

as a guide, and the two together to seek out the opening. 
When it is pushed into it and approaches the surface, the 
knife can be inserted over the point of the director and the 
fistula made complete. Then the operation is finished in the 
manner already described. A most serious condition of affairs 
is found in another form of internal fistula — viz., one which be- 
gins on the inside of the sphincter and runs around or up the 
mucous membrane. These cases go a long time without de- 
tection. The discharge from them is usually carried away 
with the fasces and escapes the notice of the patient, and it is 
only by the reflex symptoms that our attention is first drawn 
to it, such as an irritation of the bladder, the prostate, pain 
in the back and down the thighs, which can not be accounted 
for from an examination of the other parts. Then an exami- 
nation should be made of the rectum. In this instance the 
patient should not be instructed to take an enema before the 
examination, for, by so doing, the pus is washed away, but, 
having him on the table, an examination should be made in 
this manner : First, without the use of any oil or ointment, 
the anus should be gently opened with the two thumbs, and 
by a little manipulation a drop or two of pus will be seen. 
I wish to reiterate here that whenever pus is noticed escap- 
ing from the rectum, it indicates some serious trouble, gener- 
ally an internal fistula or an ulceration. After this examina- 
tion of the anus the finger should be anointed and inserted 
into the rectum and a search made for the opening of the 
fistula. We can be easily misled, however, in this examina- 
tion. We are told that a little elevated spot, or perhaps a 
depression, with elevated edges, is what we will find indica- 
tive of the opening. This may or may not be the case. We 
often find these little rough places in the mucous membrane 
of the lower rectum. A better plan is to distend the sphinc- 
ters with a speculum, and, by putting in the electric light, a 
perfect view can be had of the gut for several inches. We 
may then see a spot which has the appearance either of a 
little ulcer or an opening. By taking a long probe it can be 
then placed on this spot, and if a sinus exists it will enter 

15 



226 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 




it and likely will take a direction up the mucous membrane. 
A plan that I frequently practice is to insert the speculum, 
and, even if nothing pathological is discovered, to wait for 

a while, and we will see the 
bubbling up of a drop or 
two of pus. 

Case. — A lady came to 
me complaining with the 
many reflexes that I have 
mentioned ; also stated that 
she had localized pain in 
the rectum. She had been 
through the hands of a 
gynaecologist and also a gen- 
eral physician ; had taken 
much medicine, but was not 
relieved or even benefited, 
|jp and her symptoms at this 
time were progressing rather 
than diminishing. I made an 
examination in the manner that I have suggested, first of 
the anus, but could detect no pus ; second, with my finger 
but could find no internal opening. I then examined her 
carefully-, with the assistance of another doctor, and, al- 
though a good light was thrown into the rectum, nothing 
could be seen to account for her trouble ; but I suggested 
that we keep the speculum in situ for a few minutes and 
watch for results. After a little while the doctor said, 
"There it is," and, in looking at the spot, we saw several 
drops of pus oozing out. The probe was then introduced 
and a sinus found, extending up the mucous membrane at 
least an inch and a half. A grooved director was inserted 
through it, and it was laid open with the knife. I was not 
content with this, but trimmed off the edges of the cut mu- 
cous membrane. It was a long time before all of her reflex 
symptoms disappeared, but they eventually did so. 

I have suggested that the operation for internal fistula? of 



Electric light and cautery in case. 



TREATMENT OF FISTULA IN ANO. 



227 



this kind is a very difficult and sometimes a very serious one. 
All operators in this line recognize that cutting the mucous 
membrane to any extent in the rectum results sometimes in 
profuse haemorrhage. I have described in another part of 
the book the manner in which Mr. Gowlland, of St. Mark' s, 
deals with this kind of fistulae. Allingham, Sr., has devised 
a pair of spring scissors with probe points to be used through 
a special grooved director. The scissors can only be removed 
from the groove by drawing them out toward the handle of the 
director. This prevents the scissors from slipping out. He 
says: "With this instrument you can divide fistulge high 
up the bowel, however dense they may be, with great facility 
and quickness." It has been my experience that this form 
of fistula is not often dense, and there is no difficulty experi- 
enced in cutting through it, the chief difficulty being the con- 
trolling of the hemorrhage. 




Thermo-cautery ready for use. 

Mr. Luke, in 1845, recommended cutting through the 
diseased structures in these cases, especially when compli- 
cated with stricture, by means of a fine piece of strong 
twine and a screw tourniquet. Of course, his idea was here 
to avoid the hemorrhage that I have spoken of as attending 



228 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

such operations. Allingham substitutes the elastic ligature. 
I am not in the habit of using either plan in these cases. In 
the first place, if a stricture is complicated by fistula?, the 
latter are the result of the stricture, and we will generally find 
that there are a number of sinuses. It would be a rare case 
indeed if only one existed. It would accomplish no good, 
therefore, to lay open the tract of the fistula, but in such a 
case the stricture, being the primary cause, should be operated 
on first ; but my experience has been in dealing with cases of 
stricture complicated with fistula, beginning above the strict- 
ured surface, that an operation for fistula did more harm than 
good. My plan in dealing with internal fistula? running up 
the gut is to divide the channels by means of a grooved 
director and a knife, and either touching the bleeding points 
with a hot iron of the thermo-cautery, or plugging the rectum, 
after the manner already described. With all the ingenuity 
at our command, we will often find it a difficult thing to cure 
this form of fistula, especially if it is at all complicated — as, for 
instance, a tract or tracts running around the bowel, under 
the mucous membrane, and up the bowel. 

Case. — A lady was sent me from an adjoining State with 
the following symptoms : She had been a subject for more 
than a year of intense pain at a point parallel with the spine 
and about two inches from it in the left lumbar region. Along 
with this, she complained of a burning heat or pain inside 
the rectum. The bladder sympathized to such an extent that 
she suffered from painful micturition and a frequent desire to 
urinate. This woman was in a condition of nervous exhaus- 
tion, although physically she appeared to be a healthy 
woman. She fought against her trouble, but her mind was 
greatly disturbed by it. So prominent was this symptom that 
her husband said to me that frequently she had a confusion 
of ideas, together with a disturbed memory. Whether she 
thought herself in an incurable condition, or whether it was 
in some other manner that her mind was disturbed, she was, 
to say the least of it, a confirmed invalid. Upon the first 
examination I could not detect a sufficient amount of trouble 



TREATMENT OF FISTULA IN ANO. 229 

iu the rectum to account for her symptoms, and yet she 
referred all her trouble to that part. Upon the second exam- 
ination I found, just over the sphincter muscle, a small sinus, 
which I divided. I kept her under observation for several 
weeks, and her general health improved, but she still com- 
plained of this sensitive condition of the lower rectum. A 
few days prior to the time that she had appointed to return 
home I made an examination with the nurse, and found a 
little external opening just at the verge of the anus. Putting 
my probe into it, it ran up and entered the lower border of 
the sinus that I had divided. For obvious reasons I did not 
desire to put her under chloroform to divide this, so I inserted 
a small director through it and laid it open. This gave her 
great pain and greatly disturbed her, and I regretted after- 
ward that I had inflicted it upon her. She then remained at 
the infirmary for a while until this little wound had entirely 
healed. She returned home, but her letters to me indicated 
that she was not relieved. Although, in a general way, some- 
what better, the local condition had not improved. She 
returned to this city in about as bad a condition as she went 
away. I confess that I was nonplussed. I determined to give 
her another rigid examination, but suggested to her that when 
I did so I would also operate at the same time for any trouble 
that I might find, thereby saving the necessity of taking the 
anaesthetic twice. She was a brave woman and willing to 
submit to anything that I said. She was prepared for the 
operation and put under the influence of chloroform and a 
search of the rectum made. I used a stout director instead 
of a probe for the exploration, and, to my surprise, it fell into 
a sinus which ran down into the tissues at least an inch, be- 
ginning dorsal] y with a little inclination to the right side, and 
then taking a course through the tissues toward the perinaeum, 
coming up in front to the mucous membrane. I pushed the 
director through the membrane, and with a stout knife 
divided the tissues on it. The cut caused a profuse haemor- 
rhage. I had the wound irrigated with very hot water, and 
then the bichloride solution (1 to 5,000), and packed the 



230 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

wound with iodoform gauze, and then plugged the rectum 
after the manner that I have described in a former chapter. 
On the fifth day I removed the plug and the dressing, and 
no haemorrhage followed. For weeks the rectum was irri- 
gated daily with the different antiseptic solutions. Pus was 
kept from flowing, but the wound was a long while in filling 
up, and for two months after the operation an immense deal 
of mucus would follow each irrigation. She improved con- 
tinually after the operation, both in a local and general way, 
and was, at the last time I saw her, able to walk many squares, 
had a good appetite, and suffered comparatively little pain. 
The pain in the lumbar region, however, would appear at 
intervals, but was not very severe. 

This case illustrates that unless a surgeon is very careful 
in his investigations of the rectum, a sinus or sinuses may 
escape his observation. From the very nature of things, the 
wounds on the inside of the gut will be a long time in heal- 
ing. The faeces irritate it daily, and the sphincter muscle 
prevents a rapid cure. It also illustrates what delicate sur- 
gery has to be practiced in this variety of fistula. Frequent 
examinations, after these operations, should be made, in order 
to see that an ulcer does not result. It can not be too strongly 
impressed upon the operator that the greatest care should be 
taken in doing any cutting operation around the rectum upon 
women. The anatomical relation of the sphincter muscle is 
entirely different from that of the male, and incontinence of 
faeces will frequently result in them from these operations. 
Even a thorough dilatation of the sphincter muscle for the 
purpose of curing a fissure or irritable ulcer might result in 
this condition, and, to them, the result is of a much more 
serious nature than the disease for which the operation is 
done. 

Treatment of Fistula by Ligature. — Very great prominence is 
given by some authors to the elastic ligature as the means 
of cure for fistula. I must confess that the more I use it the 
less I am pleased with it. I never have employed it but 
that I thought that I was temporizing instead of radically 



TREATMENT OF FISTULA IN ANO. 231 

curing the patient. ~No surgeon wishes to do his work the 
second time, and this is sure to be the case if the elastic liga- 
ture is used indiscriminately. It can be very properly called 
Dittel's operation. Whereas he was not the discoverer of it, 
he has been the strongest advocate for its use. Mr. Allingham 
has employed it in more than one hundred and eighty varied 
cases, and says : "I can truly say I have over and over again 
been very glad that the utility of the elastic ligature had been 
brought forward by Prof. Dittel after it had quite fallen into 
oblivion." As I have said concerning some other operations, 
in the hands of an expert rectal surgeon and diagnostician it 
might be employed with some success ; but to say to the gen- 
eral profession, or to the student, that this is a good oper- 
ation for fistula in ano, would be the means of conveying 
a wrong impression, and one that was likely to do much 
harm. After operating for this class of disease for many 
years, I must confess my inability, in the majority of cases 
of fistula, to tell whether there is any more than one sinus 
existing or not. Now, the advocates of the ligature must 
admit the fact that, until a cut is made, no surgeon can 
tell the number of sinuses or their extent. They must also 
admit that the external opening is no guide to the amount 
of trouble that he may meet in the operation. In fleshy per- 
sons, branch sinuses of fistula? often do not begin at or near 
the surface, but radiate down through the tissues, and no 
evidence of a pipe-stem feeling is given to the finger. If these 
assertions can be verified, then it must be admitted that in all 
such cases the ligature would fail to cure. The laying open 
of a main sinus by the knife, ligature, or what not, will 
not eradicate additional branch sinuses. Again, there is 
a toughened and indurated condition of the walls of the fistu- 
lous tract. The ligature, of course, cuts only through the 
top of this, leaving the bottom untouched. I have only to 
revert to Mr. Salmon's teachings, "that if the bottom of a 
long-standing fistula is not divided, it will be impossible to 
establish the healing process." He was therefore in the habit 
of drawing his knife through the bottom of the sinus, and it 



232 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

is known to-day as Salmon's back cut. I say, therefore, with 
all deference to the distinguished surgeons that have advo- 
cated its use, that I do not believe it comparable : with the 
knife under any circumstances. Even granting that there is 
but one sinus, the knife will accomplish in a few seconds what 
it will take weeks for the ligature to do. There are four con- 
ditions, either one of which, if existing, should prevent the 
use of the ligature : 1. Where more than one sinus is known 
to exist. 2. When the fistula is of long standing and the 
walls of the sinus are indurated. 3. When the general ap- 
pearance of the parts indicates a flabby condition of the skin 
or tissues which would cause the edges of the wound to be a 
source of irritation. 4. In cases of horseshoe fistula. Believ- 
ing that this statement is true, there are therefore but few 
cases of fistula left in which the ligature would prove of 
service. Indeed, the only condition that I call to mind would 
be a fistula of recent date, superficial in character and of but 
one sinus. Even then I should be temj)ted to throw some mu- 
riate of cocaine along the route of the sinus and slit it open. 
When the ligature has cut its way through, after several 
weeks' time, it has accomplished the identical thing that the 
knife does at last — that is, a division of the tissues. So it 
occurs to me that it is simply deferring to the whims and 
prejudice of the patient against the use of the knife, not to 
consider the other arguments that I have used. Again, in 
these days of antiseptic surgery, no surgeon desires to see 
pus escaping from wounds. It would be impossible to pre- 
vent this if the ligature is used in dividing a fistula. If, after 
the ligature has cut through the tissues, it is discovered that 
there are additional sinuses, the knife must be resorted to at 
last, for they may run in such directions or be so tortuous 
that the ligature could not be used for their eradication, and 
if this procedure had to be gone through with, the patient's 
reasoning powers will teach him that it would have been bet- 
ter to have used the knife at first. Or, if it is noticed, after the 
ligature has accomplished its purpose, that the edges of the 
wound are in a flabby condition, then these flaps must be cut 




Plate V. 




FOR FISTULA r 



IGATURE. 



TREATMENT OF FISTULA IN ANO. 233 

away to insure the healing process, and to cut them away 
would be as severe as the knife would have been in the begin- 
ning. Or, if the operation has been done on an old-standing 
case of fistula, it will be observed, after the ligature has done 
its work, that the bottom of the sinus is in an indurated or 
callous condition, and, admitting that there is only one sinus, 
Mr. Salmon's back cut must be made through it to insure the 
granulating process. In horseshoe fistula no one would advo- 
cate its use. 

Advantages of the Ligature. — Allingham says: "What are 
the advantages of the ligature? Briefly these: That in sim- 
ple cases there is little or no pain inflicted by the operation ; 
the patient can walk about without danger. I have had 
many cases proving that nervous persons will often submit 
to the ligature when they will not to the knife. There is no 
bleeding — a manifest advantage in persons whose tissues bleed 
copiously on incision. I have found it useful in several such 
cases. In phthisical cases it is, in my opinion, the best means 
of dividing a sinus. In very deep, bad fistulse the elastic 
ligature is most valuable as an auxiliary to the knife. I now 
most frequently use it in this way— avoiding haemorrhage in 
sinuses running high up the bowel, where large vessels are 
inevitably met with." 

I will answer these statements briefly as follows : 

1. " That in simple cases there is little or no pain inflicted 
by the operation." I have used the elastic ligature in quite a 
number of cases of fistula in ano, and I must say that I have 
yet to see the first patient that did not say that it was pain- 
ful. A ligature that is applied tightly enough to cut through 
tissue must be painful. Certainly the pain and distress are 
sufficient to prevent the ordinary application to business, and 
in each one of my cases the patients assumed a stooping in- 
stead of the erect position, and walked with some difficulty. 
Indeed, such was their condition that they did not desire to 
move about at all. 

2. "The patient can walk about without danger." I 
once heard Prof. Richard O. Cowling, deceased, testify be- 



234 DISEASES OP THE RECTUM, ANUS AN'D SIGMOID FLEXURE. 

fore a jury that no wound was so insignificant that it did 
not call for absolute rest. The expression was one of much 
meaning and made a great impression upon me at the 
time, which I have never forgotten. To say that a patient 
can walk about without danger one can hardly be certain, 
and to say that he is abte to walk about should be no argu- 
ment in favor of the operation. The wound would be con- 
stantly irritated by any such exercise, and the flow of pus 
insured. I can scarcely consider it good surgery to allow a 
patient to walk about with a wound that has to heal by 
granulation, especially when located in the region of the rec- 
tum. Surgeons to-day consider it of absolute necessity to 
dress wounds under aseptic and antiseptic precautions every 
day, and one objection to the use of the elastic ligature at all 
is that while they are making the wound, the cut surfaces 
can not be dressed at all, and if we add to this that the pa- 
tient is allowed to walk about and attend to his professional 
or other duties, surely this condition of affairs is increased. 

3. "I have had many cases proving that nervous persons 
will often submit to the ligature when they will not to the 
knife." A distinguished specialist in the treatment of syphilis 
at Hot Springs, Ark., was in the habit of questioning his pa- 
tients as to their habits, such as the use of stimulants, tobacco, 
etc., and if he learned that they indulged in such, he would 
say to them positively that they must leave it off. If they 
answered that they would not or could not, he would say to 
them : "Then you go to some other doctor for treatment." I 
think that a good rule for a surgeon to adopt would be, if a 
patient said that he would not submit to the knife for an 
operation for fistula, when the surgeon was satisfied that the 
knife could be used and was the best, to tell him that he had 
better get another *surgeon. Surgeons often bring themselves 
into disrepute by succumbing to the dictation of patients, 
and I can see no better illustration of this than to use the 
ligature simply because a nervous person would not submit 
to the use of the knife for the treatment of a case of fistula 
in ano. 



TREATMENT OF FISTULA IN ANO. 235 

4. " There is no bleeding — a manifest advantage in deal- 
ing with patients whose tissues bleed copiously on incision." 
In witnessing a number of operations done by my friend, 
Dr. John A. Wyeth, of New York, who has the reputation of 
doing ' ' bloodless " operations, I was impressed with the 
idea that haemorrhage is so easily controlled by the au fait 
surgeon that it is to be no longer dreaded. Therefore, in 
these operations about the rectum, " tissues which bleed co- 
piously on incision " can be easily controlled by the surgeon. 

5. "In phthisical cases it is, in my opinion, the best means 
of dividing a sinus." To my mind, of all cases requiring the 
use of the knife for the eradication of fistulas, those occur- 
ring in the tubercular subject are the most important. In 
these subjects there is no well-defined sinus, but a degenera- 
tion of tissue, causing a cavity. When the cut is made, 
much flabby skin is found, and the skin itself, if not the tis- 
sues, is undermined. Add to this that different pockets are 
often found, which require scraping or trimming, and the 
ligature is certainly the worst of all methods for treating 
such cases. We all know, too, how indolent these wounds 
are, consequently how slow to heal. They require our con- 
stant attention, which should be begun from the very mo- 
ment that the operation is performed. If the ligature is 
used, we are compelled to wait until it has cut through be- 
.fore any attention can be given to the wound proper. I 
would also suggest that the effect upon the mind of a phthisi- 
cal patient wearing a ligature is anything but pleasant. 

6. "In very deep, bad fistula^ the ligature is the most 
valuable as an auxiliary to the knife." To this I would pre- 
fer the same objection as that given in No. 4. In operating 
for deep fistula I have never yet seen a condition that I would 
not prefer to use my knife throughout the whole operation. 
If blood-vessels were divided that could not be tied, pressure 
has invariably stopped the hemorrhage. 

7. "I now most frequently use it in this way— avoiding 
hemorrhage in sinuses running high up the bowel, where 
large vessels are inevitably met with." 



236 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

I have never been partial to the elastic ligature in dividing 
fistulse that run up the bowel. For such purpose I much 
prefer the silk ligature, used after the manner of Mr. Gowl- 
land, or in the ordinary way. It does its work much quicker 
and with much less inconvenience. So it will be seen that I 
dissent from each and all of the so-called advantages of the 
elastic ligature over the knife, and I submit to the profession 
whether my objections are valid or not. I have sometimes 
thought that the silk ligature, used after the manner of the old 
physicians, had some advantages over the elastic ligature. 
One is that it can be more easily applied ; another, that it can 
be only moderately tightened. The only disadvantage it has 
contrasted with the elastic ligature is that it takes much longer 
to accomplish its work, and yet these patients, who have such 
horror of the knife, can easily afford to take a longer time if 
they are freed from pain and allowed to prosecute their busi- 
ness. The manner of applying the elastic ligature is very sim- 
ple. Numerous devices have been suggested for placing the 
ligature through the fistulous tract, but I am persuaded that 
the easiest and best is to thread a very stout probe with the 
ligature, and insert it through the sinus, pulling the distal 




Allingham's ligature carrier. 

end out of the anus and placing a bullet, through the center 
of which a round hole has been made, over the two ends, and 
pushing it up with a pair of tooth or other forceps, close 
against the tissues ; then, pulling firmly on the two ends of 
the ligature, the bullet is clasped tightly. This rubber cord 
should be of sufficient strength to bear a good deal of weight, 
and should be drawn so taut as to cut through without any 
further re tightening. But if it is noticed, after a sufficient 
length of time, that the ligature is loosened and hanging 



TREATMENT OF FISTULA IN ANO. 237 

in the wound, then, by taking another bullet and cutting 
through its side, it is placed over the ligature, and, drawing 
it tightly again, the bullet is clinched. It wi]l then cut 
through the remaining tissue. Allingham, Sr., has devised 
an instrument for drawing the elastic ligature through a 
fistula from within outward that in the hands of an expe- 
rienced surgeon answers an admirable purpose. 

Treatment of Horseshoe Fistula. — This is the most serious form 
of fistula in ano with which the surgeon meets. I have never 
liked the term horseshoe fistula ; a better one would be com- 
plex fistula, because it gives a better idea of its pathology. 

In this form of fistula the idea that is meant to be con- 
veyed is that it encircles nearly completely the rectum. 
There may be only one external opening, but generally two 
internal openings. It will be seen at once that the objective 
point here is the sphincter muscle. The rule that should 
be always carefully observed is, not to cut through the exter- 
nal sphincter muscle twice at one sitting. 

Case. — A young man was brought to me, by his family 
physician, who gave the history of having had a large rectal 
abscess about a year before. It had left him with a fistula, 
the external opening being in the pernueum. He complained 
of the frequent formation of what were pus cavities in each 
buttock, which would break and discharge through this open- 
ing, and then, for an interim of perhaps several weeks, he 
would feel comparatively easy. Lately one of these cavities 
had broken through the rectum, discharging a good deal of 
pus. His general health had been impaired from the constant 
drain. I examined him as carefully as I could without an 
anaesthetic, and determined that there was a great undermining 
of tissue in both buttocks, and, extending across the coccyx, 
was a distinct feeling of a whipcord, which evidenced the con- 
nection between the two sides. I expressed to his physician 
the opinion that it would be a serious operation ; that the 
wound would be a long time in healing, and that perhaps 
the sphincter muscles would be impaired by the operation. 
We agreed to do the operation after a couple of weeks prepa- 



238 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ration, which consisted in building the boy up as well as we 
could by tonics, stimulants, and nutritious food. At the end 
of that time the operation was done as follows : The patient 
was put under ether and a long grooved director introduced 
into the external opening in the perinseum. It rapidly fol- 
lowed the large sinus which ran around on the left side and 
was forced to a point over the coccyx. A free division of the 
tissues was then made. We could then look down into this 
large, ugly wound, and, by placing my finger at its bottom, 
several smaller cavities were detected and the knife drawn 
through their bridges. I scraped it thoroughly of its debris, 
and had the wound irrigated with the bichloride solution. 
By the use of a probe a sinus was detected nearly midway of 
the cut, which ran into the bowel in a course toward the coc- 
cyx, but which included the sphincter muscle. I divided this 
sinus, and then proceeded to trim off the overlapping edges 
of skin all along the route. The whole wound was packed 
with surgeon's cotton, which had been dusted with boric acid. 
I refrained from operating upon the other side, although my 
examination showed that it was equally affected, because of 
the damage that would be done the sphincter muscle, not only 
by its division, but by cutting away so much tissue around 
it, leaving it without support. This wound was carefully 
watched, the general health of the patient looked after, and 
in six weeks after granulation had been established nearly 
to cicatrization, I operated on the other side, doing an oper- 
ation very similar to the first. It was four or five months 
before this patient could be discharged as cured, for during 
the time he was under treatment there was pocketing several 
times. 

After-treatment for Fistula. — It requires as much knowledge 
and care to carry the wound inflicted for a rectal fistula on to a 
perfect result as to do the operation. I am satisfied that just 
as many cases that result in a failure to cure are due to the want 
of a proper treatment after the operation as to the manner of 
doing the operation. Therefore I would advise the surgeon to 
keep these patients under his own observation and treatment 



TREATMENT OF FISTULA IX AXO. 239 

until a cure is effected. One of the greatest dangers to be ap- 
prehended is the confinement of pus, and another abscess or 
pocketing of the tissues. If these are not dealt with just at 
the time of their occurrence, the fistula is very sure not to 
heal, and yet a little care on the part of the surgeon will pre- 
vent this. The two places that should be watched especially 
are the beginning and the end of the wound. This is espe- 
cially true if the external opening is located either in the 
perineum or dorsally over the coccyx. A pocket is very apt 
to form just under the skin at these two places, and if a 
kuife is drawn through them soon enough they cause but very 
little trouble. It must be remembered that these wounds 
must heal by granulation from the bottom. Time was when 
surgeons thought that pus was necessary to the healing of 
the wound ; but now, if we witness it in or on wounds, we 
know that something is radically wrong. Of all portions of 
the body, around the rectum is the most difficult to prevent 
wounds suppurating ; therefore, if we have a deep wound to 
deal with, it requires the most careful watching and treat- 
ment to prevent the pouring out of pus and its being held 
in the bottom of the wound, sometimes confined in a pocket. 
Each time that it is dressed, it should be seen that the sides 
of it do not lie in apposition. We will often think that we 
have the wound distended when we open the top of it and 
look down into it ; but if we will take a small instrument and 
insert at the bottom, we will find that the granulations have 
simply united from the sides. These should be broken up at 
once. My friend Dr. Leon Straus presented me with a little 
instrument that he brought with him from St. Mark's, de- 
vised, I think, by Mr. Herbert Allingham. It is a metal rod, 
eight or ten inches long, which he uses in pulling through the 
bottom of these wounds. It is quite a neat instrument and 
answers the purpose admirably. As a substitute, if one has 
not such an instrument, I would suggest the wrapping of an 
ordinary pen-holder with a thin layer of cotton and using it 
for the same purpose. The idea is that the bottom of the 
wound must be inspected every day to see that the granuia- 



240 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

tions come up and no union takes place from the sides. It 
is a matter of some concern how to dress these wounds each 
day. For the first week my habit is to irrigate them with 
the bichloride-of -mercury solution (1 to 5,000). This, I am 
sure, is the best agent to prevent suppuration and does not 
interfere with the granulation. If the fistula has been a very 
complex one and many sinuses were divided, leaving a ragged 
wound, the very best dressing for a few days, at least, is 
Marchand's peroxide of hydrogen. This is a wonderful 
cleansing agent and has strong antiseptic properties. After 
the irrigation with the bichloride solution, I either dust the 
wound with powdered iodoform or lay a strip of iodoform 
gauze gently in the wound, pushing it down to the bottom 
with a pair of forceps. After the first dressing, the wound 
should never be stuffed or packed with anything, but simply 
a thin layer of the gauze placed between the sides. I then 
put a large piece of absorbent cotton over the wound and 
apply a T-bandage. The first dressing is usually removed 
on the second day. I believe that this is better than to 
allow it to remain three or four days, from the fact that a 
good deal of blood has oozed into the dressing, dried there, 
and acts as an irritant. The subsequent dressings are as I 
have detailed, with the exception that I frequently substitute, 
in the second week, a carbolized hot- water irrigation, or I 
make a solution of one part of campho-phenique with ten parts 
of hot water and wash the wound with it. Campho-phenique 
is a combination of refined camphor and pure chlorophenic 
acid. It prevents suppuration in fresh wounds and controls 
it in wounds at all stages. It has a local anaesthetic property 
which obtunds pain, and in this respect is preferable to the 
bichloride solution. I have carried a great number of large 
wounds to a perfect healing by the aid of these agents, which 
I again beg to repeat : Solution of bichloride of mercury (1 to 
5,000), carbolic acid, campho-phenique, and iodoform. I have 
stated in a subsequent chapter that I did not believe that there 
was anything in the way of a surgical dressing that can equal 
the powdered iodoform. In these wounds made in opera t- 



TKEATMENT OF FISTULA IN ANO. 241 

ing for fistula in ano it can not be dispensed with. It has but 
one objection, and that is its odor ; but patients have to learn 
to submit to it, just as they have to accept many things that 
they do not like. 

Proper care should also be given these patients for the 
maintenance of as good physical condition as possible during 
the treatment. It is not necessary to confine any case of the 
kind to bed for any great length of time. But this advice 
applies especially to operations upon phthisical patients. 
They should be allowed to exercise around the room or in 
warm halls. The debilitated patient should be properly fed, 
given stimulants when the physician thinks it is best, and 
tonics, constructives, etc., when demanded. A gentle laxative 
should be kept up during the entire treatment. I wish to 
reiterate that it requires as much knowledge and care to carry 
these patients through to a perfect result as any operation 
that is done in surgery. 



16 



CHAPTEE X. 

THE NERVOUS OR HYSTERICAL RECTUM. 

It has been said by some one that when the physician is 
confounded and can not make a diagnosis, he calls the affec- 
tion either hysteria or neuralgia. The general practitioner is 
often worried with his so-called hysterical cases. Since closer 
attention has been paid to nerve diseases, a clearer elucida- 
tion of their nature has been brought about. I have never 
been much of a believer in the term hysteria. From my 
observation of such cases, witnessing the symptoms, etc., I 
have always thought there was some cause for complaint out- 
side of mental impressions. The gynaecologist has found this 
out, and is to-day dealing with pathological conditions in the 
abdominal cavity which have been the main source of pro- 
ducing such disorders. Hysteria and melancholia go hand in 
hand, and by a reference to statistics we see that these pa- 
tients frequently drift into insanity. The point should be 
made out whether the cause be in the mind or in the body, 
and, having determined this, we are to go to work to locate 
the seat. Many a woman has been restored to health and to 
her family, that had been an invalid with this so-called hys- 
teria, by having a diseased ovary removed, or adhesions 
broken up in the abdominal cavity. It has become rather a 
fashionable thing to say that one suffers from nervous ex- 
haustion, and even physicians fall into error by classifying it 
among the simpler affections, when in truth it is one of the 
most serious diseases to which the human body is subject. 
To-day one of the most prominent subjects under discussion 
by the medical profession is nerve reflex, and I shall have 
occasion further on to deal with the subject in extenso. Not 



THE NERVOUS OR HYSTERICAL RECTUM. 243 

only the general practitioner, but also all specialists, meet 
with hysteria or hysterical symptoms in some way or another, 
and the rectal surgeon is not exempt from this. In the past I 
have seen a great many obscure rectal affections resembling 
hysteria in their symptoms, and I do not know of any class 
of patients that suffer so horribly as these. I censure myself, 
even at this day, in my neglect of these people. In the past 
I took it for granted that they did not suffer as much as they 
intimated, and after a partial examination I frequently gave 
them a placebo only. These people invariably drifted into 
other hands, oftentimes into those of the quack, and perhaps 
would go through life without receiving any permanent bene- 
fit. I have headed this chapter The Nervous or Hysterical 
Rectum, in deference to the title used by Goodell, who read a 
paper before the American Medical Association (Obstetrical 
and Gynaecological Section) in May, 1888. The title used by 
Dr. Goodell was The Nervous Rectum, but the term most used 
in the article was "hysteria, or hysterical rectum." I believed 
then, and believe now, that the former caption was the more 
correct. In explanation of the position that he took he said : 
" The mind is sane, the organic body is sound, the individual 
as a whole is above reproach, and yet these muscles will be- 
have as if they were bereft of reason." Again he says : "The 
muscles most liable to become hysterical are perhaps the cir- 
cular ones, namely, the sphincters of outlets or inlets ; and 
while insanity, so to speak, is more localized, the sufferings 
are perhaps greater." 

The term employed here, "hysterical rectum," is, in my 
opinion, misleading ; and while the importance of these cases 
can not be overestimated, I am sure that the matter would be 
better understood if he had written of "some obscure affec- 
tions of the rectum," for the reason that it invites investiga- 
tion. Any surgeon who has had much to do in the way 
of examining the rectum has met with cases where the patient 
complained much when but little if any disease was found. 
Now, I will be permitted to say that I think the reason is 
that we frequently dismiss these patients without a thorough 



244 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

examination. When one comes to .us complaining of a dis- 
turbance in the rectum, we naturally expect to find some of 
the ordinary diseases, such as haemorrhoids, fistula, ulcera- 
tion, or perhaps cancer ; but it requires a little longer time 
and a good deal more trouble to have the rectum washed out, 
the patient put in a proper position, and a search made for 
some small lesion, which, under the circumstances, is very 
apt to exist and to be the cause of all the symptoms that 
the patient may complain of. But if we come to the con- 
clusion, without this examination, that this patient is hysteri- 
cal, we are too apt to put her upon a nervine, or perhaps a 
tonic, and dismiss her. The result is that we never see her 
again as a patient. Webber defines hysteria to be "a dis- 
eased state of the nervous system evidenced by an almost in- 
numerable variety of symptoms." 

Recognizing to-day the power and manner of the reflexes, 
we had better say that we can have a diseased condition, 
simulating hysteria, caused by disease or an irritability of the 
periphery of a nerve. It is too common to class these patients 
as suffering from a functional nervous disease, when in reality 
it may be from a pathological condition at the terminal end, 
and not central, attended with nervous symptoms. Goodell 
further says, in speaking of the hysterical rectum : "In this 
form of hysteria there is usually present, in my experience, 
some one of the Protean symptoms of general nerve prostration, 
such as spine-aches, backaches, sore ovaries, weariness, wake- 
fulness, and nervousness ; but the chief suffering of the most 
exacting symptom is referred to some portion of the rectal 
tract, leading the physician to suppose that he is dealing with 
some coarse or traumatic lesion. The act of defecation then 
gives great suffering, followed by a painful throbbing, which 
may last for hours. Patients thus afflicted so dread the suf- 
fering that they school themselves into habits of costiveness, 
and often become victims of opium-eating.' ' 

This is a perfect description of this class of patients, many 
of whom would prefer death to such a life, and we would not 
be stating the case too strongly were we to say that this con- 



THE NERVOUS OR HYSTERICAL RECTUM. 245 

dition will often end in actual insanity. In my experience as 
a specialist, I have had two cases to be confined in an insane 
asylum from just such a cause. But is Goodell correct when 
he says that such a case "may lead the physician to suppose 
that he is dealing with some traumatic lesion ' ' ? Would it 
not be stating it more definitely, correctly, and to the point, 
to say that in such a case the physician is dealing with a 
traumatic lesion ? Can any one doubt, after reading a descrip- 
tion like that given above of the hysterical rectum, that he 
has a diseased condition of the rectum to deal with % Where 
could you find a better description by any author of an 
ulcerated rectum than is given here: " Nerve prostration, 
spine-aches, backaches, sore ovaries, weariness, wakefulness, 
and nervousness " ? Now, in a general way, almost any spe- 
cialist, especially the gynaecologist, could account for these 
symptoms by referring the origin to the ovaries, tubes, or 
uterus. The general practitioner would find many conditions 
that would produce like symptoms, but in a further perusal 
of the case we are told that the chief suffering, or the most 
exacting symptom, is referred to the rectal tract. Now, we 
would naturally look to this tract for an explanation of the 
trouble. It either must be that there is some disease there, 
or by a reflex action the symptoms are made manifest in the 
rectum. Be that as it may, we are dealing with a pathologi- 
cal condition. Either the disease is located in the rectum, 
and by reflex is making the spine ache, ovaries tender, etc., 
or the disease is in some other part, and is reflected to the 
rectum by its nerve distribution. But a further study of the 
case aids us in making the diagnosis. " The act of defecation 
then gives great suffering, followed by a painful throbbing 
which may last for hours. Patients thus afflicted so dread 
the suffering that they school themselves into habits of cos- 
tiveness." I think rectal surgeons will bear me out in saying 
that in ninety-nine cases out of a hundred an examination of 
a patient suffering from these symptoms would reveal a lesion 
in the form of a fissure, irritable ulcer, ulceration proper, or 
it may be a peeling off of the epithelium, if not the mucous 



246 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

membrane. I am certain, then, that in such cases, first, a 
lesion exists, and that the disease can not be cured until said 
lesion is eradicated. Secondly, if in these cases a lesion can 
not be found in the rectum after a long and diligent search, 
then they must be set down as a reflex condition, and by our 
knowledge of anatomy we shall either trace it out, or send it 
to a specialist who can do so. Since I have taken this view of 
the case I have given my patients a more careful examination, 
and have usually found a lesion, and by a treatment of the 
same I have usually cured them ; or if I was satisfied that the 
symptoms were those caused by reflex from some other dis- 
eased part of the body, I have referred them to the specialist to 
which they belonged. If it is a female, she is usually sent to 
the gynaecologist. If a male, he is sent to the genito-urinary 
surgeon. These cases are more common than they are be- 
lieved to be by the general practitioner, and they merit our 
closest scrutiny and care. 

Case I. — A young girl came to me who had been treated for 
three years for chronic diarrhoea. The least excitement would 
cause her bowels to move. She had on an average six to 
eight evacuations a day. If a stranger came into the room, 
she had to rush for the water-closet. She could not go into 
society for this reason. For three years she had taken no 
nourishment, by order of her physician, except stale bread, 
milk, and weak tea. She had "Protean" symptoms of nerve 
prostration, backache, wakefulness, nervousness, etc., to- 
gether with a burning sensation at defecation, and an aching 
pain hours afterward. I gave this girl a careful examination, 
and found a sensitive spot in her rectum. Under chloroform 
I divulsed the sphincter muscles and touched the spot with 
nitric acid. She made a rapid recovery. In a few days all 
looseness of the bowels had disappeared, and she ate a full 
meal three times a day. 

Case II.— Dr. J. G. Carpenter, of Stanford, Ky., thus re- 
lated to me a case in his own person : " I was the victim once 
of this spasmodic contraction of the sphincter ani muscles. 
Often, when riding on horseback and feeling perfectly well, I 



THE NERVOUS OR HYSTERICAL RECTUM. 347 

would be seized with a sudden pain in the rectum, the sensa- 
tion passing all over me as if I were struck by lightning, 
causing me to drop the reins in agony of seemingly impend- 
ing death. A few weeks would elapse before another attack. 
On every sudden change of the weather I was affected. 
Forcible dilatation of the sphincter cured me." 

Case III. — William B., aged forty-eight, was sent to me 
suffering from the following symptoms : At the approach of 
defecation he felt a severe pain up in the rectum, thought by 
him to indicate the passage of the faecal mass over a sore place. 
During the act a lancinating pain was experienced, and after 
evacuation a dull, throbbing, aching sensation which lasted 
for hours. A nervous exhaustion supervened, which com- 
pletely unfitted the patient for any mental or physical labor. 
This condition lasted about two years. The symptoms seemed 
clearly to call for the divulsion of the sphincter. This was 
done under chloroform, and the patient was promised a cure. 
Several weeks after, he reported at my office, saying that he 
experienced no relief whatever, and expressed a desire and 
hope that he would die, so terrible was his distress. I then 
carefully examined him again, and could find no lesion what- 
ever. Recognizing the powerful effect of the reflexes in these 
cases, I advised that he go to a genito-urinary surgeon and be 
examined for a stricture of the urethra. This he did, and was 
told that he had both a meatic and deep urethral stricture. 
These were divided by the surgeon, and the man was relieved 
of all his distress. 

Case IY. — Dr. H., of Indiana, asked me at one of the 
medical societies to examine him after he had given me the 
following history : Several years ago, while pursuing his pro- 
fessional duties, he was attacked by a fearful pain in the rec- 
tum. It was as if a sharp knife had been thrust through him. 
It would come up as paroxysms, with a few moments only of 
intermission. He hastened to procure chloroform, and inhaled 
it at each approach of the paroxysm until it disappeared. He 
now carries a bottle of chloroform with him, and regards it 
as his best friend. Indeed, he says nothing would induce 



248 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

him to part with it. He would go for weeks perhaps without 
an attack. Placing him in bed, I examined the rectum care- 
fully with the index linger. I had no instruments with me. 
I gave it as my opinion that a lesion existed, perhaps only 
the exposure of a sensitive nerve, and if a free divulsion of 
the muscle should not effect a cure, the lesion should be 
sought for and a local application made to it. He afterward 
consulted Dr. Cook, of Indianapolis, who gave him a careful 
examination with the speculum, and agreed to the diagnosis 
I had made. An operation was not done. We met him 
months afterward, and he reported that he had never had 
another attack, but he still carried the chloroform. 

Case V.— A professional gentleman, sitting in his office 
with his feet elevated, felt a quick, sharp pain dart through 
the rectum, near the verge of the anus. These pains came 
quick and often. He jumped to his feet and called for help. 
A friend, coming in at the time, caught him as he was in the 
act of fainting. The attack lasted about twenty minutes and 
was quieted by opium. I directed that he be taken home, 
and that suppositories of belladonna and opium be adminis- 
tered for their full effect. The patient had three other at- 
tacks in so many days, after which all intimation of rectal 
disease subsided, but I should add that his rectum had been 
treated during this time by free washings out with hot water 
and the use of suppositories. 

Case VI.— Dr. W., of the southern part of this State, 
came to me less than a year ago complaining that at the act 
of defecation he suffered a tormenting pain, which lasted 
from one to four hours, and then during the interim, between 
the acts of defecation, there was a dull, heavy feeling of 
weight experienced in the rectum, extending to the perinseum. 
It completely unfitted him for his country practice. An ex- 
amination revealed a congested condition of the vessels just 
at the verge of the anus, with one or two sensitive places 
around the gut. My assistant gave him chloroform, and I 
freely divulsed the sphincter muscles. He expressed himself 
as greatly relieved, and on the fifth day returned to his home. 



THE NERVOUS OR HYSTERICAL RECTUM. 249 

In two or three months thereafter he began writing me that 
there had been an entire subsidence of his trouble, but that 
he was satisfied it was coming on him again. The symptoms 
increased rapidly, and after the expiration of several months 
he came back to me, suffering as much or more than he had 
previously. A friend of his said to me : " All of this man's 
trouble is in his mind" ; but the doctor said : "I believe that 
if you will practice a little cutting, with the free divulsion of 
the muscle, it will cure me." So the next day Dr. Dugan 
saw the case with me, when we agreed to administer an anaes- 
thetic and to do as the patient had suggested. I forcibly 
divulsed the sphincter, feeling it give way in its entirety. 
Then I inserted a speculum, and held it, while Dr. Dugan 
thoroughly scarified the gut. In less than three hours after 
the operation the patient said: "I feel now different from 
what I did after the other operation, and I am satisfied that 
I am cured." He went home on the sixth day, and I have 
heard nothing from him since. This case not only proves 
what I have said — that a lesion exists — but it also demonstrates 
that there are many cases in which the divulsion alone will 
not accomplish a cure. The nerve filaments that were ex- 
posed in this man's rectum had their sensibility destroyed by 
the use of the knife. 

Case VII. — A physician living near my office sent his 
servant after me with the message to come as quick as I 
could to see him. I did so, and found him in the most ago- 
nizing pain. He said that an hour before this, pain had 
begun in the rectum, seemingly without cause, and that it 
was unendurable. He had taken opiates freely, and had in- 
haled chloroform. He expressed the belief that it was caused 
by spasm of the sphincter muscle. I asked him to allow me 
to examine him digitally, and he reluctantly consented. I 
found the muscle spasmodically contracted, and it was with 
a good deal of difficulty and pain that I succeeded in getting 
the finger beyond it. This, however, I accomplished, and 
found just beneath the prostate gland an indurated and de- 
nuded spot. After the removal of my finger he said that he 



250 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

felt that that small amount of dilatation had done him good. 
I suggested that he allow me to chloroform him and divulse 
the sphincter. As the majority of physicians would have 
done, he refused, but suggested that I send him a dilator in 
the form of a bougie, that he could introduce himself. This 
I did, substituting an oval speculum with a conical guide, 
and, by anointing it, he pushed it into the rectum and held 
it there quite a while. This procedure he kept up for some 
time, and, together with injections, suppositories, etc., he 
got over his attack in a few days. Unless that abrasion is 
cured, he is liable to have another attack at any time. 

Cases I, II, IV, and V were evidently traumatic lesions, 
causing the exposure of a nerve, and Case III was due to a 
traumatic stricture of the urethra, and the pain in the rec- 
tum was entirely reflex. All the rest of the cases were 
proved to have originated from disease in the rectum, though 
very difficult to find. Therefore I say if these diseases are 
relieved by local measures, it proves the affection to be local, 
or, more properly speaking, pathological, and not hysterical ; 
primary, and not secondary, in its nature. If they had been 
hysterical, the local treatment would not have given relief, 
but a constitutional course of treatment would have been 
necessary. Groodell says in his article : " Sometimes the site 
of the rectal pain lies higher up than the sphincter muscle, 
and is irrespective of the act of defecation. It is then liable 
to be periodical in its character, coming on at regular hours 
of the day, probably from the periodicity with which the 
accumulation of faeces in the lower bowel takes place." 

According to this statement, I can not believe in the idea 
of hysteria attacking a muscle, for the reason that the above 
is not a description of any unique condition found in the rec- 
tum, but is a very common one to the rectal surgeon. It is 
an every-day affair for the patient to say to us that the pain 
lies higher up than the sphincter muscle, and is not con- 
nected with the act of defecation. Investigation of these 
cases has demonstrated to me the fact that it requires a very 
little lesion to produce such symptoms. The books usually 



THE NERVOUS OR HYSTERICAL RECTUM. 251 

refer to ulcers, or ulceration proper, as producing them, but 
in many instances I have found that the simple peeling 
off of the epithelium at certain spots is sufficient to bring 
about such a condition of affairs. In other words, I do not 
think it necessary that the gut should be ulcerated, and I 
know of no term to express exactly this condition, and yet 
through the speculum I have often seen it, and have called 
attention to the fact that it accounts for haemorrhage some- 
times from the rectum. In former years I was in the habit 
of searching for a well-defined ulcer, and paid very little at- 
tention to the condition of which I am now speaking, but by 
experience I was taught that it was of more importance than 
I deemed it, and yet I was more or less excusable, for the 
reason that I had never had my attention called to it by 
any of the text-books, and the truth of it goes to prove a 
fact which is pertinent to this question — that it requires a 
very small amount of change from the normal condition to 
produce the symptoms of which we have spoken. The very 
fact, as Groodell says, that the trouble is periodical in its 
character, coming on at regular hours of the day, probably 
on account of the periodicity with which the accumulation 
of faeces in the lower bowel takes place, will incline the rectal 
surgeon at least to suspect some abnormal condition in the 
bowel. I think that we can dissipate here all idea of " hys- 
teria" attacking the muscles. The muscle which would 
likely be affected — the external sphincter — is not in contiguity 
with the disease proper. Those that have observed these 
diseases with much precision have found that, when the 
lesion or abrasion is located in this part of the rectum, the 
sphincter is not made to respond to nerve irritation, but 
that we get the symptoms through other organs or by the 
reflexes. It is only pressure upon or disease of the nerves 
which supply the sphincter that produces the irritability and 
the so-called spasmodic action of the muscle itself. For in- 
stance, if we have what is called an irritable ulceration en- 
croaching upon the sphincter muscle, we will have the tor- 
menting and agonizing pain of fissure, and yet in my practice 



252 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

I have known many instances of ulceration to exist in the 
bowel for a sufficient length of time to produce a strictured 
condition of it, and yet the patient had complained of but 
little pain. Indeed, such persons are more apt to come to 
you to be treated for constipation than for ulceration. I 
would therefore prefer to consider for the balance of the 
chapter what we could more properly term 

Obscure Diseases of the Rectum. — I believe with Webber that 
hysteria can be defined as "a disease of the nervous system 
having no recognized pathological condition. " I certainly be- 
lieve that it is impossible for a muscle to be attacked by such 
disease ; but whenever we have evidences such as have been 
described, they are, in my opinion, the result of disease at the 
seat of trouble, or by reflex from continuity of structure. 
Under the latter condition we will find disease as the cause 
of such symptoms located somewhere. If either one of these 
propositions be true, then the idea of such diseases being 
"hysterical" in their nature can not be sustained. The pro- 
fession has fallen into the habit of accepting the ordinary 
definition for hysteria, which is that it simply means an as- 
suming of symptoms when no disease exists. A better term 
for such manifestation in the rectum would be neuralgia, 
although, in the ordinary sense and application of the word, 
that is a misunderstood and a misapplied term. There are 
very many pathological conditions which exist in the rectum, 
any of which could, and do, present all the symptoms of the 
so called hysterical rectum. I can not, therefore, too strongly 
urge the necessity of a careful examination to detect these 
changes. For instance, the rectum because of its peculiar 
office, of its deficiency of valves in the venous supply of 
blood, of the dependent position, etc., is quite liable to a con- 
gested state, if not to an inflammatory one. Of course, the 
term congestion would signify that there was too much blood 
in this part, and that its return through the veins was im- 
peded ; hence we would have the so-called varicose condition 
existing here which is termed by some authors li&mor- 
rJioidal. Although I do not believe that a dilated vein or 



THE NERVOUS OR HYSTERICAL RECTUM. 253 

a varicose vein, if you please, constitutes a hemorrhoid, yet 
I am satisfied that this is the incipient state which will lead 
to the hemorrhoidal condition, if not overcome. But, as I 
have mentioned, you may have this congested condition, at- 
tended with some inflammation ; and just as you could have 
varicose veins in the lower limbs, followed by ulceration, so 
you can have it here. Authors are in the habit of dealing 
with this state of ulceration as a consequence of the exist- 
ence of haemorrhoids. This is a very different state of affairs 
from the one of which I am speaking. In hemorrhoids we 
can only have ulceration as a condition resulting from fric- 
tion, brought about by frequent protrusion, etc., and I would 
mention that it takes a long time to produce such a condi- 
tion ; but where the blood-vessels are strutting from an over- 
distention of blood, it is very easy to understand that by 
the pressure of hardened feces as an irritant or of a dis- 
placed womb as an obstruction to the return of the flow, we 
could have a lesion in the vein wall which would terminate 
in an ulceration. Therefore I am inclined to the belief that 
although the theory usually given for the production of the 
hemorrhoidal condition is correct, I am satisfied that that 
which is initial of the hemorrhoids — namely, the congested 
blood-vessels — is also initial of the ulceration, etc., that is 
found in the rectum. As a cause of obscure disease of the 
rectum I mig-ht mention foreign bodies which frequently 
lodge in the pouch and produce distress, if not trauma. 

Case. — Several years ago a lady patient was sent me from 
Bowling Green, Ky., for examination. She said to me that 
she believed she had cancer, and a note from her physician 
implied that that was his opinion. This woman suffered with 
really an obscure condition of affairs. She did not have any 
acute pain, but said that she was always miserable — pain in 
the back and the thighs, and a general lassitude. She had 
lost much flesh, was constantly thinking of herself, and re- 
marked that she had no special desire to live. I attributed 
this more to her belief that she was suffering from malignant 
trouble than anything else. Placing her on the table, I intro- 



254 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

duced my finger into the rectum, and immediately above the 
external sphincter, toward the perinaeum, I felt a hard, nodu- 
lar lump, which could be very well circumscribed. The rest 
of the gut seemed to be healthy. She gave no history of an 
abscess or of an acute inflammation of any kind. I told 
her, after the examination, that I thought an operation was 
necessary, which meant a free removal of the tumor. The 
next day she was attacked with pneumonia, and was attended 
by a physician friend in this city. After her recovery she 
was in such a debilitated condition that her physician ad- 
vised her to return to her country home and remain there 
until she was sufficiently recovered, in a general way, to 
undergo the operation. I did not hear from her for months, 
when one day I met a relative of hers in a hotel, who said 
to me: " Did you hear how that case turned out?" Not 
having heard from her at all, I said that I was ignorant of 
anything concerning it. He then told me that a few weeks 
before, while suffering from a diarrhoea, which was a common 
thing with her, she had gone to stool, and, in her effort to pass 
everything from the bowel, strained vigorously, but felt that 
there w T as something which would not pass. So she intro- 
duced her own finger into the rectum, and, feeling a hard sub- 
stance there, hooked the finger around it and pulled it out. 
And what do you suppose it was 3 " said the man. I had to 
confess my ignorance. " Why," said he, "it was a large jaw 
tooth with a perfect gold filling." I asked him if she gave 
any history of swallowing this tooth, and he replied that she 
did, saying that eighteen years prior to this, in the extraction 
of a number of teeth, she remembered to have swallowed one. 
It had become imbedded in the tissues of the rectum and 
remained there, and afterward ulcerated through. It is need- 
less to say that all her "obscure" symptoms disappeared. 

It is a very easy matter to wound the delicate mucous mem- 
brane at the verge of the anus, and if a lesion is once started, 
however small — even too small for detection — these obscure 
symptoms will result. In many instances one passage of 
hardened faeces is quite sufficient to accomplish the result. 



THE NERVOUS Oft, HYSTERICAL RECTUM. 255 

The use of rough substances as a detergent, in which list I 
might include common printed paper, will accomplish this. 
The enema tube is known to be a frequent cause of such 
trouble, or the openings of internal fistulse too small for de- 
tection may cause all of these obscure symptoms. 

In a succeeding chapter, on the anatomy of the rectum in 
relation to the reflexes, I shall deal more explicitly with such 
disorders as proctitis, injuries to the uterus, or diseases of it, 
stricture of the urethra, cystitis, enlarged prostate, etc., 
which are common causes of these obscure symptoms. Until 
these abnormal conditions are cured it will be impossible to 
have the so-called hysterical symptoms disappear. Of one 
thing I am certain : that in not one single case, be it of a 
hysterical nature or one with obscure symptoms from what- 
ever cause, have they been benefited by constitutional treat 
ment in my hands. Besides these common diseases of the 
rectum, or, I may say, these obscure diseases of the rectum, 
there is another class that can not be described or accounted 
for by the symptoms or conditions which I have mentioned. 
Prof. Goodell gives a very excellent description of the con- 
dition to which I refer. He says: " There is yet another 
form of disease which I think may be classified under the 
general heading of nervous rectum, although its pathology is 
by no means yet fully understood. I refer to pellicular coli- 
tis, or pseudo-membranous enteritis, as it is usually termed, 
in which mucous casts of the lower bowel are discharged, with 
much tenesmus and abdominal pain, either by themselves or 
in the regular evacuation." 

In my opinion, these cases are not unique, but quite a 
number of them are to be seen by the rectal surgeon in the 
course of a year, and I can not agree that the disease, for 
disease it is, is a " sheer neurosis." I have seen the affection 
in patients not given at all to hypochondriasis, and relief has 
been obtained by remedies outside of those that affect the 
nervous system ; or, in other words, it has been treated as a 
local disease, and not as a nervous disease at all. I believe 
that in all of these cases a disease exists, the result of patho- 



256 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

logical change, as the names colitis and enteritis imply, 
namely, by inflammatory action. I have never yet succeeded 
in curing such a case outside of direct or local medication. 

iEtiology. — The rational treatment of all disease necessarily 
depends upon a correct diagnosis. How difficult this some- 
times is, all practitioners of medicine, as well as specialists, are 
aware ; but I believe that specialism has done much toward 
elucidating the subject of diagnosis. It often occurs that a pa- 
tient suffering from some obscure malady has passed through 
the hands of many general practitioners and a few specialists, 
until at last some one has discovered the seat of disease and 
effected a cure. I can not believe that the medical profession, 
as a whole or in part, is so selfish as to detain a patient for 
treatment who rightfully belongs to another. My experience 
has been that whenever this point has been determined by either 
the general practitioner or the specialist, the patient is sent 
where he rightfully belongs, or is thought to belong. In deal- 
ing with this subject of the u nervous rectum," a term which 
of itself implies a doubt, it has been my object to demonstrate 
that an argument must be based upon clinical facts before a 
position is taken, and in regard to these affections I will state 
again that I believe that they have their local origin in the rec- 
tum, and that all nervous manifestations are secondary to it. 
If this premise be admitted, then the line of treatment is plain. 
Eelieve the cause (local), and the manifestations (general) 
will disappear. If the premise is wrong, and these troubles 
are "neurotic" — i.e., caused by a disordered condition of 
the nervous system— then the term " nervous or hysterical 
rectum " is the correct one, and the line of treatment would 
be to correct the general condition, and the local symptoms 
will take care of themselves. Now, I wish to say that I have 
seen some few cases where it was impossible for me to make 
out the pathological change, or to account for the symptoms 
by any of the reflexes, and that I was nearly forced to the 
conviction that they were the result of a "sheer neurosis," 
because sometimes the condition is very remarkable and diffi- 
cult to explain. But even granting that I was unable to find 



THE NERVOUS OR HYSTERICAL RECTUM. 257 

the lesion or to locate the reflex, I would not be warranted in 
taking the position that the trouble was not caused by patho- 
logical change somewhere. 

Case. — A young lady was advised to come to me from a 
city in Pennsylvania, quite along distance. While sitting, nar- 
rating her case to me, she gave a sudden start and fell across 
the chair from the effect of a most terrific pain in the rec- 
tum. Although I gave her a hypodermic injection of a fourth 
of a grain of morphine, and another in the course of thirty 
minutes, it was more than an hour before she became quiet. 
She then told me that she had had these attacks at intervals 
of two to three weeks for several years, and that within the 
last year they occurred nearly daily and sometimes two or 
three times a day. She was afraid to go out on the street 
alone because of them, and had given up her gentlemen 
friends on this account. She was a very prepossessing girl, 
in good flesh, weighing about one hundred and forty pounds, 
and showed evidence of a good, generally healthy condition 
by the rosy color in her cheks, a good appetite, etc. She re- 
marked that if she could be relieved of this local disease she 
would be perfectly well, but rather than bear it another year 
she would prefer death. She described these attacks just as 
I had witnessed this one— namely, as a sharp, quick, lanci- 
nating, terrible pain, just within the rectum, lasting from a 
few minutes to several hours. It had no reference to the act 
of defecation at all, nor to the condition of the bowel, whether 
she was suffering from constipation or diarrhoea. The symp- 
toms were somewhat aggravated and the attacks more fre- 
quent during the time of her monthly sickness. I examined 
her rectum diligently and carefully a number of times, but 
could find no trouble. I had my assistant give her ether, and 
I forcibly divulsed the sphincter muscle, thinking that this 
would relieve her, and so told her. While under ether I care- 
fully examined the upper rectum, but still found no disease. 
This divulsion did her no good. Hearing her complain at one 
time of some pain at micturition, I had my friend Dr. W. H. 

Wathen to see her, and he thought it a good idea to divulse 

17 



258 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

the urethra, which he did. This accomplished no good. As 
I mentioned, she suffered more at the time of her menses, and 
Dr. Wathen advised that the cervix be divulsed. This he 
also did, both of us thinking that possibly we would trace the 
reflex to this origin. Like the others, this operation was per- 
fectly nil in its effects. The attacks went on. I should say 
that during all this time I was medicating the rectum locally. 
I applied a solution of nitrate of silver, injected large quan- 
tities of very hot water, used other injections, of the fluid 
hydrastis, hydrate of chloral, pinus canadensis, etc., all of 
no avail. I invited her upon one occasion to go before the 
Louisville Surgical Society, which met at my residence, said 
society being composed of twelve of the leading surgeons of 
the city. I had each and all of them to question her closely, 
and they could not advise anything more than had been done 
for her relief. She remained in my infirmary four months, 
and concluded at the end of this time to return to her home 
in Pennsylvania. The evening before her departure I called 
at the infirmary, found her in great distress in one of her 
attacks, and asked her if she had taken the hot water injec- 
tion that I had ordered. She said she had ; that it did her no 
good. I said : " Suppose you try a cold-water injection," and 
left her. The next morning I called and found this girl walk- 
ing through the hall in an erect position ; her natural position 
since she was first attacked was a stooped one. I said to her : 
" Why, what's the matter \ " She replied : " Why, don't you 
know that I haven't felt the least pain since taking that cold- 
water injection yesterday evening, and can walk with perfect 
ease % " This was such glad news that I told her to discard 
everything else and use the cold-water injections. She left 
that night for Cincinnati. Two days thereafter she wrote me 
that she had had no further pain ; that she had walked eleven 
squares that day and had done some shopping. I did not hear 
from her again for ten days or two weeks, when she wrote me 
that she had had only one slight intimation of pain and had 
called in her family physician, who wished to prescribe, or 
did prescribe, some of her old remedies, which she declined 



THE NERVOUS OR HYSTERICAL RECTUM. 259 

to use. That was one week before she wrote me. She had 
not felt it since, and remarked that the night before writing 
me she had attended a ball, the first one in years, and had 
danced a number of times without any inconvenience at all. 
She continued to improve, and eventually ceased to write. 

Now, this case I am at a loss to understand. It comes 
nearer to being one of "a sheer neurosis" than anything that 
I have ever seen. Could it be that this trouble was neuralgic 
in character, having its origin probably in the exposure of a 
small filament of a nerve, and that the cold water so impressed 
it as to overcome its sensibility, according to the common 
aphorism in surgery, that if heat does not accomplish the de- 
sired purpose cold will % 

In tabulating the causes, therefore, of these " obscure af- 
fections of the rectum," I would have to restrict them to two 
heads : 1. The reflexes. 2. A lesion or pathological change 
at the seat of trouble. 

I must confess that of all vague terms used by a physician, 
this one, hysteria, is the vaguest. Having reference, as the 
derivation of the word implies, to the womb, the profession 
has been in the habit of characterizing many affections of the 
female which we could not understand as hysterics ; but so 
many symptoms analogous to these are presented in the male 
that we frequently see articles descriptive of them and the 
same term used, I do not deny that the nervous system is 
responsible for many strange freaks, but I do assert that much 
that is attributed to it has its origin in the periphery and not 
in the nerve-center. To-day is the era in medicine of the 
study of these nervous diseases, and I look for the time to 
come when many of them that are now classed as obscure 
may be made as plain to us as others which we do not doubt. 
I can not, therefore, believe in the " nervous rectum "per se, 
but would enforce again the necessity in all such cases of 
finding out the origin of the trouble by the closest scrutiny. 

As this chapter will be followed by one closely allied to it 
— namely, The Anal and Rectal Reflexes — I shall not deal 
with the treatment of these diseases just now. 



CHAPTER XL 

NEURALGIA OF THE RECTUM. 

Under the head of the hysterical or nervous rectum I have 
already discussed the cases which are commonly called neu- 
ralgic, but as in that chapter I did not deal with neuralgia as 
a term, I desire to say something more of it. E. P. Hurd, in 
his excellent book upon neuralgia, defines it as u a neurosis 
whose essential symptom consists in a lancinating pain, par- 
oxysmal in character, described as boring, burning, stabbing, 
localized in nerve trunks or their terminal branches ; apyretic, 
without redness or apparent swelling ; generally accompanied 
by secondary phenomena of a motor, vaso-motor, or secretory 
or trophic nature." He agrees with Anstie in considering that 
neuralgia occurs only in those subject to some impairment of 
general health. 

Allingham says: "I can see no reason why neuralgia 
should not sometimes attack the rectum as well as any other 
part of the body." This, to my mind, is a perfectly true 
statement, and yet I have seen so many cases in a general way 
that were called neuralgia, in which I doubted the correctness 
of the statement, that I am loath to name any affection of the 
rectum neuralgia without a thorough investigation. As will 
be observed, in referring to the chapter on The Nervous or 
Hysterical Rectum, I take the position that all cases of irrita- 
ble, nervous, or hysterical rectum are due to a well-defined 
lesion ; that the pathological condition is oftentimes difficult 
to detect, and in many instances can not be observed at all. 
In the cases that I shall now report I failed to find the lesion. 
Am I to believe that none such existed ? Are these cases due 
solely to a special diathesis, neuralgia, or to the reflexes, the 



NEURALGIA OF THE RECTUM. 201 

disease originating in some adjacent organ or tissne ? I be- 
lieve firmly in the reflexes as accounting for pain, and yet in 
some instances they could be entirely ruled out. In such I 
believe that a pathological condition, such as congestion, in- 
flammation, or may be the simple exposure of a filament of a 
nerve, will account for the so-called neuralgia. I have been 
greatly interested in this subject, more especially for the 
reason that Hurd gives in his book, when he says that he is 
obliged to admit that, in spite of the imposing array of reme- 
dies, the neuralgic pain will refuse to surrender, and we are 
obliged in the end to capitulate ourselves and have recourse 
to the cowardly hypodermic syringe. This is a sad condition 
to contemplate, and if we can change the opinion that these 
cases in the rectum that simulate neuralgia are in reality due 
to a lesion, we stand a much better chance of curing this un- 
fortunate class of patients. In this connection I desire to 
report a few cases : 

Case I. — In the early part of 1891 I saw a patient who 
gave the following history : Aged fifty-three, small in stat- 
ure, nervous and melancholy in disposition, free from all evil 
habits. He complained of a local pain in the rectum, not ag- 
gravated by an action from the bowels. An examination of 
the rectum revealed no lesion, but his symptoms pointed so 
clearly to one, or at least to an exposed nerve, that I ventured 
the opinion that he could easily be cured by divulsing the 
sphincter muscle. This was done under an anaesthetic, and 
after a short time he reported at my office, saying that the 
operation had done him no good. He escaped my notice for 
several months, and during this time had consulted a number 
of physicians and taken many remedies without effect, and at 
last came back to me. I subjected him to a rigid examination 
but could find no particular trouble. I again divulsed the 
sphincter, this time doing it more thoroughly, and coated the 
whole of the lower surface of the rectum with a forty-per-cent 
solution of nitrate of silver. No better result was obtained 
from this operation than from the first. I sent him to a genito- 
urinary surgeon, who detected a stricture of large caliber and 



262 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

divided it, thinking, perhaps, that this might relieve some 
reflex. The operation, however, had no appreciable effect. 
The man had taken all manner of tonics, etc., but he con- 
tinued in the same old way, and a greater melancholic I have 
never witnessed. There was not a moment in the day but 
that his mind was on his rectum. 

Case II. — A lady, about fifty years of age, in apparently 
good health, was referred to me with symptoms very like 
Case I. I made the same promise of relief if the sphincters 
were divulsed. This was done, but no relief followed. This 
case took a course very similar to the other one. Numerous 
physicians were consulted, and her family physician, who 
was an eminent man in the profession, did everything in his 
power to relieve her, but to no purpose. The symptoms are 
those of neuralgia — a dull, aching pain, always present in 
the rectum, but not aggravated by a movement from the bow- 
els. She is nearly a monomaniac upon the subject of her 
trouble. We have just agreed to send her to a gynaecologist. 
Case III. — A woman, about forty years of age, weighing 
about one hundred and eighty-live pounds, gave the follow- 
ing symptoms : She had a tormenting pain which she referred 
to the rectum, but, as she expressed it, the pain was located 
high up. She said there was no special pain during the act 
of defecation, but that generally before she went to stool she 
suffered abdominal pain, which frequently continued for an 
hour or two. I examined the rectum and could find no dis- 
eased condition. I advised her to take copious injections of 
hot water, and also put her upon Goodell's pill compound, viz. : 
5 Ext. sumbul . . gr. j ; 

Asafcetida gr. ij ; 

Ferri sulph. exsic gr. j ; 

Acid, arseniosi g r - fV • 

M. Sig. : Four to be taken during the day. 
She took this prescription for some time, but without effect. 
It was not until several weeks had elapsed, while during a 
conversation she remarked that she had forgotten to tell 
me that she had suffered from what the doctor called a pelvic 



NEURALGIA OF THE RECTUM. 263 

abscess, which had discharged through her rectum. This of 
course put a new phase on the matter, and I sent her to a 
gynaecologist, who afterward told me that her pain was evi- 
dently due to adhesions in the abdominal cavity, and that he 
had recommended a laparotomy. I never heard any more of 
the case. 

I might go on and recite a number of such cases, but these 
will be sufficient to convey my views. In the chapter on the 
hysterical rectum I have taken the position that all such 
cases are due to a lesion, exposure of the filament of a nerve, 
and in the chapter on the reflexes I contend that if the source 
of the reflex is ascertained and corrected, the so-called neural- 
gic pain will disappear, and therefore that these cases do not 
fall under the head of neuralgia at all. If a nerve filament is 
exposed, it is the exposure that causes the pain. If there be 
a lesion or trauma, the pain is due to the injury. I do not, 
therefore, consider that the neurosis which constitutes neu- 
ralgia exists. Anstie says that neuralgia occurs only in 
those subject to some impairment of general health. I am 
sure that the majority of such cases, as observed by me, 
have been in persons of robust health, and I must rule out 
cases of pain in the rectum caused by reflex from this class. 
It is a well-known fact that persons suffering from fissure, or 
from any disease of the rectum which causes pain, become 
nervous and hypochondriacal, and although Allingham says 
that these sensations continue after the ulcer has healed, it 
has been my experience that when they were relieved of the 
rectal irritation and pain these other symptoms disappeared. 
Dolbeau, of Paris, considers the essence of fissure to be neu- 
ralgic, and defines fissure of the anus as being a spasmodic 
neuralgia of the anus, with or without fissure. I certainly 
can not subscribe to any such view as this. The first portion 
of the sentence, that fissure of the anus is the cause of pain, 
which perhaps resembles the neuralgic pain, is correct, for this 
theory fully corroborates what I have said— that a lesion 
exists which accounts for the pain, and therefore neuralgia 
is ruled out ; but to the latter portion of the sentence, that a 



264 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

" spasmodic neuralgia of the anus may exist with or witliout 
fissure," my position is that if there is no fissure and yet 
pain, it must be by reflex, and therefore not neuralgic. The 
pathological changes of inflammation, etc., which would go to 
make up a neuralgic condition of the nerve do not exist in 
these cases ; but when the point of reflex is ferreted out and 
stopped, no further disturbance of the nerve in the rectum is 
observed. It is very true, as Hurd says, that so far as the nerve 
trunk or terminal branches are concerned it may be ' ' apyret- 
ic, without redness or apparent swelling." We are very well 
aware of the fact that one or more of the symptoms of inflam- 
mation proper may be absent, and yet an inflammatory condi- 
tion exist. If a tooth aches and the dentist discovers that it 
is due to the exposure of the nerve, he would be inclined to 
prevent the exposure, yet in a case of facial neuralgia we would 
treat the nerve both locally and constitutionally. Some con- 
sider the spasm of the sphincter muscle as the cause of this 
neuralgic pain. I would argue that if the premise be true, it 
would not be a neuralgic pain, but simply one caused by spasm 
of the sphincter implicating a nerve. But I can not believe 
the premise true, from the fact that I believe the spasm of the 
sphincter to be caused by the lesion. This is very well illus- 
trated in cases where we have a mass of hardened faeces lying 
in the pouch of the rectum. A congestion and an abrasion 
exists in consequence of the foreign body, and excites the 
sphincter muscle to spasm. Allingham says: "I have been 
in the habit of calling pain in the rectum or sphincter muscles 
neuralgic when I have not been able to find out the slightest 
lesion, sign of inflammation, or discharge of any kind, and 
where the pain was not aggravated by action of the bowels. 
This I always consider an important point in diagnosis." 

This is very like the custom of some practitioners of pro- 
nouncing affections which have certain symptoms as mala- 
rial, when said symptoms may be brought about by constipa- 
tion or a faulty liver. Small doses of calomel in such cases 
have oftentimes done more good than many grains of quinine, 
and also by its administration the diagnosis was cleared up. 



NEURALGIA OF THE RECTUM. 265 

They say that charity covers a multitude of sius. I am sure 
that when I was in general practice the terms malaria and 
neuralgia covered a multitude of my errors. So I am inclined 
to think about calling pain in the rectum neuralgic when we 
can not find a lesion. I quite agree with Allingham when he 
says " an important point of diagnosis is whether the pain is 
aggravated by the action of the bowels." But this neuralgic (?) 
condition of the rectum is frequently cleared up by dividing 
a stricture in the urethra or doing an abdominal section upon 
the woman. Allingham also says : "I have noticed the attack 
follow direct exposure to wet and cold by sitting upon damp 
grass." This is quite a different case, for here we have an 
exciting cause for the inflammatory condition of the nerve, 
together with the congestion of the blood-vessels. The ques- 
tion naturally resolves itself into this : Are these cases due 
solely to a special diathesis, and occur only in the debilitated 
and nervous person, or are they due to some reflex, the disease 
originating in some adjacent organ or tissue, or is the pain 
referable to the point where it is made manifest, say to a lesion, 
or exposure of a nerve in the rectum \ For my own part, I 
believe that these so-called cases of neuralgia are due, first, to 
a lesion in the mucous membrane of the rectum, and the con- 
sequent exposure of a nerve filament, or, second, the source of 
trouble is not in the rectum at all, but is reflected from some 
other organ or tissue. If the case falls under the first divis- 
ion, and the erosion, abrasion, or what not, is close to the 
sphincter muscle, the pain is aggravated during the act of 
defecation ; and if it is from the second condition, the pain is 
not aggravated during this act. Therefore I am inclined to 
believe that the term neuralgia as applied to these cases is 
a misnomer. 

Treatment.— A careful examination should be made of the 
anus and rectum. It is sometimes the case that a very 
minute sinus may exist in the folds just at the verge of the 
anus and be overlooked. It may be that over the sphincter 
muscle or higher up the rectum there is a peeling off of epi- 
thelium or an abrasion of the mucous membrane. Therefore 



266 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

a good speculum should be employed, the room darkened, 
the patient put upon the table, and, when the instrument is 
opened in the rectum, the electric light after the manner de- 
scribed should be introduced and a careful search made for 
the abraded surface. If it is found, a probe with a thin film 
of absorbent cotton wrapped around its end should be 
dipped in pure nitric or carbolic acid, and the abraded sur- 
face touched with it. If the sphincter muscle is irritable 
and pain exists during the act of defecation or following it, 
the sphincter muscle should be divulsed. If no lesion can 
be found, and the sphincter is not irritable, we are to sup- 
pose that this pain in the rectum is reflected from some other 
source, and each and every organ, connected by nerve influ- 
ence with the rectum, should be carefully inspected and 
asked after, and then the patient referred to the specialist to 
whom he belongs. I have never found that any anti-neural- 
gic medication did these patients any good at all, and, as I 
have already said, they were not such subjects as called for 
quinine, iron, strychnine, or any other tonic. But one point 
I wish to thoroughly impress, and that is that these patients 
should not be allowed to take opium for their relief, for it is 
this very class of patients that become habituated to its use. 
It has been my observation that hot-water injections ag- 
gravate the trouble instead of lessening it, and in several 
'instances I have seen marked benefit result from the use of 
cold water injected into the rectum, although, of course, I 
could not suggest this as a general rule. I wish to reiterate 
what I have said before— that, of all agents to prevent rectal 
troubles as a class, cold water will be found the most service- 
able. This especially applies to congestions, inflammations, 
atony, hsemorrhoids, both external and internal fistulse, etc. 



CHAPTER XII. 

IEEITABLE ULCER OE FISSTJEE. 

Theee is an anatomical as well as a pathological differ- 
ence between fissure and an irritable nicer of the rectum. 
Fissures are found at the verge of the anus, and should, 
therefore, be called anal fissures. Indeed, a fissure proper 
could not exist within the rectum. It is necessary to make 
this distinction because the treatment depends upon it. I 
think the setiology should be considered somewhat in mak- 
ing up our verdict. A consideration of the anatomy of the 
lower part of the rectum aids us very materially in the con- 
sideration of the subject. The predominant symptom devel- 
oped by a fissure of the anus, or of an anal ulcer, as you 
please, is pain, and this is made so from the implication of 
the external sphincter muscle in the trouble. I think in 
dealing with this special subject, or in rectal disease in gen- 
eral, we overlook the importance of the external sphincter 
muscle and overestimate the importance of the internal 
sphincter muscle. I am sure that I have seen cases where an 
ulcer was situated over the internal sphincter muscle, and 
was, to a remarkable degree, painless ; and yet, when the 
smallest number of fibers of the external sphincter muscle are 
implicated in the ulceration, pain is a very prominent symp- 
tom. Although the two muscles are in close apposition, it is 
the external sphincter which controls the outlet and responds 
in cases of danger. Hilton has pointed out the important 
fact that the nerves — principally branches of the pudic — 
which come down below the internal sphincter, pass out be- 
tween the muscles at the junction to become superficial in 
this situation. 



268 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

'Now, it will be observed that an ulceration could exist 
above Hilton's white line and over the internal sphincter mus- 
cle, and yet not engage the nerve distribution. But whenever 
there is an encroachment made upon the external sphincter, 
the nerve-supply is made to respond. It is a well-recognized 




Nervous supply of anus (Hilton.) a, mucous membrane of rectum ; 5, skin near the anus; 
c, external sphincter muscle ; d, internal sphincter muscle ; <?, line of separation of the 
two sphincters ; /, the overlying white line marking the junction of the two sphincters ; 
g, nerve supplying the skin near the anus, which it reaches by passing first externally 
to the rectum and then through the interval between the two sphincters ; h, flap of mu- 
cous membrane and skin reflected back. 

fact that ulcers located above the sphincter muscle cause 
very little pain, and I have already cited several cases where 
an ulceration extended around the gut in its entire circum- 
ference above the external sphincter muscle, and yet pain 
was not spoken of at all. Gosselin divides these ulcers into 
two distinct varieties — the tolerant and the intolerant. Mol- 
liere suggests the terms tolerable and intolerable. I like 
the division of Gosselin better. I am satisfied that the di- 
vision line between the tolerant and intolerant ulcer is Hil- 
ton's white line. In other words, if the ulcer be located 
above this line, it is tolerant ; if located below, it is intoler- 
ant. Quite a good deal of discussion has originated over the 
cause of this spasm which we find in fissure of the sphincter 
muscle. Boyer considered it antecedent to and the cause 
of the fissure ; and Yan Buren was more or less inclined to 



IRRITABLE ULCER OR FISSURE. 069 

this idea. Ball says : " I have never, however, been able to 
observe this condition, as it has always appeared to me that 
the muscular contraction involves the whole circumference 
of the sphincter, and, in any case, the distinction appears to 
me to involve a frivolous and practically worthless refine- 
ment." 

To my mind, there can be no doubt that the existence of 
a fissure or an irritable ulcer, if properly located, produces 
the spasm of the sphincter ; and I could under no circum- 
stances believe that the spasm of the sphincter produced the 
irritable ulcer or fissure. It is not necessary to have much of 
a lesion to bring about this spasmodic action of the muscle. 
Exposure of the smallest filament of a nerve is sufficient to 
accomplish it. In many cases it is not necessary to have a 
lesion or trauma to produce this irritability of the muscle. 
It is a well-known fact that many of the reflexes will produce 
this — for instance, from the urethra, prostate gland, a dis- 
placed uterus, the retention of the urine, etc. On the other 
hand, the irritable sphincters from fissure, ulceration, etc., 
produce many of the reiiexes ; but this subject has been 
spoken of in detail in the chapter on the anatomy of the rec- 
tum with relation to the reflexes. A fissure of the anus may 
be caused in many ways, but, of course, they are generally 
attributable to traumatism. Many persons suffer an irrita- 
bility of the sphincter, etc., from the fact that the skin sur- 
rounding the anus is very delicate and easily impressed ; 
hence, by the use of improper articles for detergent pur- 
poses, they may, by friction or otherwise, injure the cuticle, 
and the filament of a nerve is exposed, or the passage of hard 
and dry faeces may break the mucous membrane at the verge 
of the anus, and, because of the constant operation of the 
sphincter muscle, it refuses to heal and becomes an ulcer 
from pathological changes. A marginal abscess which has 
left a small sinus amounts in substance to a fissure with all 
its symptoms. Where pruritus exists and the patient volun- 
tarily or involuntarily scratches himself with some force, he 
breaks the skin, and the spasm of the sphincter muscle after- 



270 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ward prevents it from healing. In shape, too, a fissure of the 
anus is different from an irritable ulcer of the rectum. A 
fissure appears as a distinct cut through the mucous mem- 
brane, extending from a few lines to an inch in length, run- 
ning into *the rectum. An irritable ulcer is generally oval, 
with distinct edges, with a reddish, sometimes a gray, base, 
discharging pus. The same character of ulcer, located higher 
up the rectum, would not be called irritable ; but the differ- 
ence of the shortest space characterizes it as either tolerant 
or intolerant. Kelsey says : u Although these ulcers are gen- 
erally stated to be due to an act of laceration of the mucous 
membrane, or to its abrasion from some irritation, they not 
infrequently originate within the sinuses of Morgagni, and a 
true fissure may be entirely concealed from view within one 
of these pouches." 

Theoretically, I can not believe in this source as explaining 
the symptoms of fissure. In the first place, there is no ex- 
posure of the nerve filament in the sinuses of Morgagni, and, 
in the second place, the anatomy does not permit of its being 
embraced by contraction of the sphincter muscle, as in the 
other forms of fissure. I have never met with such a case in 
my practice. Fissures of the anus are usually located dor- 
sally ; for what reason I can not explain, except, perhaps, 
that this portion of the anus is more immovable, being con- 
nected more or less with the coccyx. However, we may find 
a fissure or an irritable ulcer in any portion of the anal cir- 
cumference. I believe that they are more common in adult 
life. In infancy, the sphincters are not well defined, and con- 
sequently can not act with decided spasmodic force. In old 
age the parts are more or less atrophied and the nerve sensa- 
tions are blunted. If these ulcers are more 'common in women, 
it is simply because the skin is more delicate. Children are 
sometimes affected with this form of trouble. 

Case I. — A lady brought a three -year- old son to me with 
the following symptoms : She had noticed for several weeks 
that every time the child's bowels moved it would cry out 
with pain, which only lasted for a few minutes ; but the little 



IRRITABLE ULCER OR FISSURE. 271 

fellow had learned to anticipate and to dread an evacuation. 
She had examined the child and found nothing to account for 
his trouble. Placing him in his mother's lap and opening the 
anus gently, I could see a slight abrasion, dorsally situated. 
Recognizing that it required but little lesion here to produce 
pain, I took a small speculum, introduced it into the rectum, 
and rubbed the abraded surface with my finger. I directed 
the mother to give this child an enema of sweet oil each morn- 
ing preceding the evacuation. I did not see her again for two 
weeks, when she told me that the child was entirely relieved 
by what I did for him. 

Case II. — A mother brought her infant in arms to me, 
complaining that the child was very restless and apparently 
suffered a good deal of pain, especially when its bowels 
moved. An examination in the anus did not reveal any 
abrasion. But, acting upon the suggestion brought about by 
the result of other cases of the kind, I anointed my finger, in- 
serted it in the anus, and swept it around the aggregation of 
fibers. To the point of my finger it was evidenced that there 
was a little accumulation of faeces in the pouch of the rectum. 
I ordered that the child have an enema of hot water for sev- 
eral consecutive days. The next report was that there was no 
further trouble. 

A number of times I have been consulted by physicians 
for suggestions in cases of this nature, and in each I have 
suggested that the finger be anointed and inserted in the 
rectum of the child without any attempt at divulsion. If it 
is necessary, this method can be practiced each day until 
a cure is effected. There is no rectal affection that pro- 
duces such powerful reflexes as an irritable ulcer or fissure 
of the anus. But as I have devoted special attention to 
these in another chapter, I think it necessary only to refer to 
them here. 

Examination and Diagnosis. — The symptoms are so pronounced 
in fissure or irritable ulcer that a surgeon can usually make a 
correct diagnosis without an examination, although an exam- 
ination should be made in each and every case. But when- 



272 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ever a patient presents himself complaining of the character- 
istic pain of fissure, whatever he may have in conjunction 
which may have been diagnosticated by a physician as piles, 
polypi, cancer, fistula, or what not, I know that he has, in 
addition, an irritable ulceration. In making an examination, 
the first thing observed may be an external pile, or a marginal 
fistula, or a protruding polypus, or an evidence of internal 
haemorrhoids, or perhaps a syphilitic ulceration of the bowel, 
or cancer ; for each and all of these can be the cause of an 
irritable ulceration within the grasp of the sphincter. But 
whether they exist or not, the circumference of the anus 
should be examined and the rectum searched for this form of 
ulcer or fissure. 

Ordinarily, by placing the patient in Sims's position on the 
left side, by the aid of a good light we can see an irritable 
ulcer or a fissure of the anus. The first thing observed, where 
a fissure engages the sphincter muscle, is a small, oval tumor 
of the integument, just at the verge of the anus. I believe 
that my friend Dr. Richard O. Cowling, deceased, was the 
first to state that this little tumor was pathognomonic of 
fissure. Since he called my attention to it many years ago, I 
have found that his statement was correct. It has been 
mooted by some whether the tumor caused the fissure or, vice 
versa, the fissure caused the tumor. There can be no doubt 
that the latter is correct, for the growth is simply an enlarged 
piece of skin at the lower extremity of the fissure, caused by 
plastic infiltration. The passage of the finger into the rectum 
where an irritable ulcer exists causes a great deal of pain, 
which is likely to last for a considerable time after the exam- 
ination, and yet, with a little dexterity, this can be averted. 
Suppose the fissure is located dorsally : Anoint the finger 
well with vaseline or lard, and, in making the attempt to 
introduce it into the rectum, have it press upon the front 
portion, and then, using some force, insert it. Or, if the fis- 
sure be located toward the perinseum, press dorsally upon in- 
troducing the finger. This examination by the finger reveals 
very little in a case of fissure of the anus. After it is intro- 



IRRITABLE ULCER OR FISSURE. 273 

duced, we are not able to feel any pathological change, un- 
less the ulcer be one of long standing and is indurated, hav- 
ing distinct edges and base. It is more, however, for the 
purpose of ascertaining if there is any complication — as, for 
instance, the existence of any of the diseases which I have 
mentioned. At the upper part of the fissure a small growth, 
polypoid in form, may be felt. This is not a polypus, in fact, 
but is produced by inflammatory changes, just as the larger 
growth at the bottom of the fissure. If my patients dislike 
an examination digitally because of the fear of pain, I am not 
in the habit of subjecting them to it, for the reason that, if 
an operation is done, anything that exists can be seen at that 
time and attended to. 

Symptoms. — Of all diseases within the scope of the surgeon, 
a well-pronounced fissure or irritable ulcer is the most pain- 
ful. This is especially so when we consider the insignificance 
of the lesion, and yet, of all known cases requiring the sur- 
geon's skill, this can be the most easily and most radically 
cured. I have seen grown men cry like babies with the 
affection. 

Case I. — A young bank cashier telephoned me to stop at 
his bank, which I did, when he said to me : ic I have a painful 
rectal trouble which I wish you to relieve." I asked him his 
symptoms, and he said that for a number of weeks he had 
experienced some pain at each act of defecation, but latterly 
it had become unbearable. Upon questioning him and find- 
ing that he had no symptoms of haemorrhoids or other rectal 
disease, I suggested to him that upon going home that night 
he should take a purgative, the next morning do without his 
breakfast, and await my coming, wdien I would have my 
assistant give him an anaesthetic, and I w^ould cure him of 
his trouble. He replied that he w 7 ould do without his break- 
fast and take the chloroform, but that he would not take the 
purgative. I asked him his reason, and he replied that his 
bowels had not acted for tw T o w r eeks, and that he would not 
permit them to act for all the money in the city, and added 
that he would die first. Of course this was an explanation of 

18 



274 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

the great pain that he suffered during the movement of the 
bowels. I did the operation next day for fissure by forcible 
divulsion, and was compelled to remove a fsecal impaction 
from the pouch of the rectum. 

Case II. — Dr. S. B. Mills, of this city, asked me to see a 
patient with him who was suffering from some rectal trouble 
and was in great distress. We repaired to the residence and 
arrived there some thirty minutes after the man had had an 
evacuation of the bowels. He was bent over a chair in a com- 
plete curve, groaning and crying with pain. Otherwise he 
was a strong, healthy individual. He refused to be examined, 
because of the fear of pain, unless we gave him chloroform. 
This was done, and a well-defined irritable ulcer was found 
just within the rectum, over the external sphincter muscle. 
A free dilatation of the muscle was practiced and the ulcer 
scarified. In a few days this man returned to his home in 
the country entirely cured. 

To show how insignificant the lesion may be that causes 
this intense pain in fissure, I will recite the following case : 

Case. — One of the learned physicians of the city said to 
me that he had a lady patient from the country under ob- 
servation who was complaining of a complication of troubles, 
among which there was a kidney, bladder, and rectal com- 
plication ; that he had examined her carefully a number of 
times, but could not find sufficient trouble to account for 
her great distress. We went together to see the patient, 
when she gave me the following history : She said that for 
a year or more she had had more or less pain during the act 
of defecation, but that for the last six months her life was 
one of torture ; that now not only did she suffer most ago- 
nizing pain in the rectum each and every time that the 
bowels moved, but also that the action of the kidneys was 
also accompanied by distressing pain. She had lost thirty 
pounds of flesh within the year, and labored under the im- 
pression that she had cancer somewhere. The physician had 
ruled out this opinion, however, and yet was unable to ac- 
count for her symptoms. I had her lie upon a hard bed, 



IRRITABLE ULCER OR FISSURE. 275 

with the buttocks elevated, assuming Sims' s position. By 
gently opening the anus and having the patient strain down 
1 could see the beginning of a small tear in the bowel, but 
not of any considerable extent. I called the physician's at- 
tention to this spot, and he replied that he had made a 
similar examination and had seen that abrasion, but that it 
had not occurred to him that so slight an affair could pro- 
duce her symptoms. As an examination would be very pain- 
ful, I suggested that chloroform be administered and that 
we divulse the muscle, and if any other disease existed in 
connection with the fissure, it could then be attended to. 
She was anaesthetized, and with a speculum I divulsed the 
sphincter muscle, and the crack in the mucous membrane 
could be seen at the end, in an oval ulcer with a grayish 
base and indurated edges, located just over the sphincter 
muscle. No other disease existed. I completed the dilata- 
tion of the muscle with my fingers, then, reinserting the 
speculum, I brought the ulcer into view and scarified it 
freely. With a little after-treatment this woman entirely 
recovered, the reflexes to the kidney and bladder disappear- 
ing from the time that I did the operation. 

We have observed in the recital of one of these cases that 
the patient had been allowed to suffer for many months with 
a disease that was eradicated in a few minutes. Very often 
patients who are the victims of irritable ulcer have told me 
that not only was the case diagnosticated as some other affec- 
tion, but also that they had been advised not to have any 
operation done. It is, to say the least of it, cruel for a prac- 
titioner of medicine to give any such advice. 

Case. — A woman, aged about fifty, sent for me to see her, 
that she might be relieved by medicine of a terrible pain 
from which she was suffering in the rectum. Upon arriving 
at her house, I found her writhing in agony, and ascertained 
that the bowels had just moved. She said to me that she 
must have some medicine to quiet this terrible pain. In 
questioning her about her case, she informed me that she had 
had rectal trouble for about six years, and during this time 



276 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

she had suffered more than she thought any human being 
could bear. I made an examination, and found just at the 
verge of the anus, and extending into the rectum, a large, 
ugly ulcer, with a border that amounted to flaps of angry- 
looking skin. The whole surface was discharging a bad- 
looking pus. I asked her why she had never been operated 
upon. She told me that she had some lung disease, and 
that she had been advised by her friends, also by a physician 
at one time, not to have any operation done for the fear that 
it would increase the trouble in her lungs. It was hard to 
imagine that this statement could be true after seeing this 
rectal ulceration and witnessing this woman suffer her ter- 
rible pain. To be told that such had existed for six years 
without any effort at relief was impossible to believe, and yet 
the case verified the statement. I suggested to her the ad- 
visability of an operation, and, after taking time to consult 
with her friends, she at last consented, and so notified me. 
I appointed a time and, in company w T ith my assistant, went 
to the house, gave her ether, divulsed the sphincter muscle, 
scarified the ulceration, and trimmed away all of the over- 
lapping edges. It is needless to speak of the relief that this 
poor woman received. 

The character of pain experienced from irritable ulcer or 
fissure is peculiar. Sometimes it begins during the evacua- 
tion of the bowels, but I am inclined to believe that this is 
more the case in irritable ulcer than it is with fissure of the 
anus!. In irritable ulcer, therefore, in the act of defecation, 
a smarting sensation is noticed, and just following the move- 
ment of the bowels a burning pain is experienced, which may 
last in some cases not longer than ten or fifteen minutes. 
Some blood or mucus may be observed generally on the ac- 
tion. In fissure proper the patient will tell you that very 
little pain, if any, is noticed during the act of defecation, but 
that in about twenty minutes it begins as a sharp, lancinating 
pain, as if a knife had been stuck into it, which gradually 
increases for perhaps thirty or forty minutes, and then be- 
gins to subside as a dull, gnawing pain, sometimes resem- 



IRRITABLE ULCER OR FISSURE. 277 

bling a toothache. This interim between the movement of 
the bowel and the accession of pain I believe to be pathogno- 
monic of fissure, for I do not know any other rectal affection 
that acts after this manner. As I have suggested, fissure or 
fissures of the anus may be secondary to some other disease 
of the rectum, as, for instance, produced by the slipping out 
and in of a polypus. Now, it would do very little good to 
operate for a fissure and allow the polypus to remain, and 
yet this has been done from allowing the polypus to escape 
notice. It is different, however, when a fissured condition of 
the anus exists in benign or syphilitic ulceration of the bow- 
els. It will be found that by stretching the sphincter muscles 
the pain, which is the most important factor in the patient's 
trouble, is relieved, and the ulceration can be treated after- 
ward. I believe that it is easy to differentiate between fissure 
and other diseases of the rectum. I scarcely see how any 
confusion could occur, except perhaps with an internal fistula, 
or, as Yance has suggested, where a cul-de-sac exists in one 
of the sinuses of Morgagni. And yet I have made several 
mistakes in operating for fissure, where I allowed the real 
trouble to escape my notice. 

Case. — A lady came to me from the country complaining 
of pain in the rectum which was increased during the action 
of the bowels ; yet she complained of pain all the time in that 
neighborhood. She was in the habit of sitting in a cush- 
ioned chair, for the reason that, when on a hard seat, she 
experienced discomfort. The pain was characteristic of fis- 
sure, and, upon examination, I had found an abrasion at the 
verge of the anus ; I divulsed the sphincter muscles freely, 
and assured her that she would be relieved. She, returned 
home, and was in comparative comfort for several months, 
when she noticed that her "old trouble" was coming back 
again. She returned to the city, and I made a rigid exami- 
nation and found that a little internal sinus had begun at 
the verge of the anus and extended up the bowel about an 
inch. A probe passed readily through it. I slit it up with- 
out giving the patient an anaesthetic, and this effected a cure. 



278 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

We can not be too particular in making a thorough ex- 
amination in all cases of disease of the rectum. I have had 
many women consult me for pain at the lower part of the rec- 
tum, and at first glance one would suppose from their de- 
scription that they were suffering from an ulceration in this 
locality, but by careful inquiry it would be found that the 
pain had none of the characteristics of a fissure pain, but was, 
on the contrary, a dull, aching, heavy sensation, which can 
nearly universally be traced to a displaced womb. These 
cases should be referred to the gynaecologist. The discharge 
from the rectum in cases of fissure or irritable ulcer is gener- 
ally very small — indeed, often escapes the notice of the pa- 
tient. It is generally muco-purulent and sometimes bloody. 
In some cases of fissure, especially during their early exist- 
ence, I have known as much as a teaspoonful of blood to be 
lost at a time. This is rare, however, for the ulceration 
seldom bleeds. Sometimes irritable ulcers are multiple, but 
generally only one exists, and that one is not often larger 
than a five-cent silver piece. Fissure is sometimes caused by 
a difficult labor and may require subsequent treatment, but 
with a little care local applications will effect a cure. Where 
I find a well-defined fissure or irritable ulcer in the female, 
complicated with a displaced womb or other uterine trouble, 
I make it my invariable rule to operate for the fissure first, 
and send them to the gynaecologist afterward. Mr. Ailing- 
ham says that he has many times had reason to repent inter- 
fering with theee cases, and adds that the successful treat- 
ment of the uterine disorder may be sufficient to cure the 
fissure. Now, I think that this depends altogether upon cir- 
cumstances. I can not understand how an irritable ulcer 
or a fissure with its attendant pathological changes in the 
structures can get well by relieving an anteverted cr a retro ■ 
verted uterus, or by curing any uterine complication. I can 
understand how, by the pressure of the child's head in 
utero, a small pile is formed, which will disappear when 
the pressure is relieved by delivery ; but when we have this 
well-defined fissure or ulcer of which I am speaking, I am 



IRRITABLE ULCER OR FISSURE. 279 

sure that nothing less than an operation for the same will 
cure it. 

Treatment. Palliative. — When I see a well-marked case of 
fissure or irritable ulcer, I must confess that a palliative treat- 
ment does not look reasonable ; first, because it takes such 
a long time to produce a cure, and, second, because by an 
operation it can be relieved at once. 

Case. — A business man came to my office saying that he 
had some rectal trouble, and, although it caused him a great 
deal of pain and distress, he did not have the time to quit his 
business and lie up for an operation, and that, besides this, 
he was afraid to take an anaesthetic. An examination showed 
an irritable ulcer with a well-defined base and indurated bor- 
ders. This was situated over the sphincter muscle, and a fissure 
had crept down the margin of the anus from it. I explained 
to this man how simple the operation was and how radical it 
would be, relieving him entirely in a very short time, and 
that he would be kept from his business only a few days. 
He, however, would not submit, intimating that he knew 
another doctor (?) who had promised to relieve him without 
an operation. I advised him to go to him, as I did not pro- 
pose to temporize in the treatment of his case in that manner. 
I did not see him again for four months, when, accidentally 
meeting him, he told me that he was still under treatment. 
An operation would have permitted him to return to his busi- 
ness in four days entirely relieved. 

However, there are cases which perforce of circumstances 
can not be operated on. In such we have to pursue the fol- 
lowing plan : First, have the patient clear the intestinal tract 
by taking a good aperient. He should then be provided with 
a mild laxative to keep on hand in order to keep the bowels 
gently soluble. The preparation known as syrup of figs 
answers very nicely for this purpose. Its purgative action is 
obtained from the use of senna. Children especially can take 
this medicine easily. However, any good domestic remedy, 
such as sulphur, magnesia, or a combination of the two, can 
be used in the ordinary doses. I then begin treatment by 



280 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

having the patient wash out his bowel for several days with 
copious injections of hot water, and then I direct that after 
each action of the bowels he is to inject into the rectum one 
ounce of olive oil containing live grains of iodoform. It is a 
bad plan in these cases to give any injection which contains an 
opiate. I know of no better way to establish the opium habit. 
As far as an application by the patient in the form of ointments, 
etc., is concerned, it seems absurd to try them, for the reason 
that it would be impossible to anoint the finger with said 
ointment and push it into the rectum. If any one desires to 
test this matter, let him try it after the manner I have indi- 
cated, and see if all the ointment is not on the lower portion 
of the finger when it is withdrawn, and the tip of the finger is 
free of ointment. As a substitute for the finger, an ointment 
carrier will be found a good thing. 

If you have one of these in your possession, it can be filled 
with the ointment, when, by introducing the instrument into 
the rectum, the ointment can be deposited. But one objec- 
tion to the use of this instrument in irritable ulcer or fissure 
is the pain it excites ; consequently I would rather rely upon 
other methods of treatment. If an ointment, however, is de- 
sired, I would suggest the following : 

9 Vaseline 5 j ; 

Iodoform 3 j ; 

Carbolic acid gr. xxx. 

M. A small portion to be used each day with the carrier. 

If the ulcer or fissure is at the verge, where it can be seen, 
then an ointment may be used with some purpose ; but in the 
vast majority of these cases only a small portion of the ulcer 
can be brought into view. My plan of treatment is as fol- 
lows: I get the patient's consent to place himself under my 
observation until he is cured, and I have him report at my 
office as often as it is necessary. After an aperient has been 
taken, I direct that, before the patient comes to see me, he is 
to wash out the rectum with hot water. I place him on the 
table, and taking a small bivalve speculum, I gently insert it 
into the rectum, the blades being made to escape the fissure ; 



IRRITABLE ULCER OF FISSURE. 281 

I gently open it. The patient will have some fear of this 
procedure the first time that it is done, but he generally ex- 
periences some relief on even a slight divulsion and will not 
object to it the next time. When the ulcer is brought into 
view by the speculum, if I find that it is inclined to be indo- 
lent, I touch, its entire surface with pure carbolic acid. I 
prefer this to nitrate of silver, because it is a local sedative 
and does not cause as much pain as the silver, and stimulates 
just as well. Before withdrawing the speculum, I deposit 
some vaseline upon the ulcerated surface. On the second 
visit, which is about the third or fourth day after the first 
one, I again insert the speculum, and this time blow upon the 
ulcer, by means of an insufflator, powdered iodoform, or depos- 
it the powder upon it by means of a spatula. This is one of 
the best agents that can be used in the treatment of this 
affection. If I had to rely upon any one single agent in the 
treatment of an ulcerated rectum, I would select iodoform. I 
now direct this patient to use an injection each night at bed- 
time of one ounce of oil and five grains of iodoform. An 
excellent remedy as a local application will be found in the 
hydrate of chloral in a strong, even a saturated solution. It 
has a fine stimulating effect ; besides, it is a local anaesthetic. 
I invariably direct these patients to precede the action of the 
bowel each time by an injection of tepid water, the tempera- 
ture each day being gradually reduced until the injection is 
of water that has stood on the dresser over night. I have 
found that the use of hot water in these cases, continued for 
any length of time, aggravates the trouble. On the contrary, 
I have got excellent results in the use of cool, not cold, water. 
But the rule must be in these cases to do an operation for 
their relief. 

Operation. — Mr. Allingham says, in dealing with this sub- 
ject : " I have headed this chapter Fissure and Painful Irrita- 
ble Ulcer, because the symptoms and treatment do not differ, 
whatever form the ulcer assumes, whether it be elongated and 
club-shaped, oval, or circular." 

In the beginning of this chapter I said that I believed that 



282 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

the two affections, for I so regarded them, should be consid- 
ered under separate heads, for the reason that the treatment 
depended upon such division. To follow out Mr. Allingham's 
quotation will go far to give my reason for what I have said. 
It is : u But, as a rule, the small circular ulcer is situated 
higher up the bowel than fissures are, which generally extend 
to the junction of the mucous membrane with the skin, the 
ulcer being more commonly found above or about the lower 
edge of the internal sphincter." 

Now, when we come to speak of the treatment of fissure 
and irritable ulcer, I shall take occasion to say that all cases 
of fissures of the anus, with the rarest exception, are curable 
by divulsion of the sphincter muscles, and that the majority of 
well-developed irritable ulcers require a division by the knife, 
not of the sphincter muscle but of the ulcer itself. Even as 
to the palliative treatment of the disease or diseases, oint- 
ments can be applied to some forms of fissures which are ex- 
ternal to the sphincter, but in the majority of these cases the 
disease is within the sphincter muscle, and to which the oint- 
ment could not be applied, because it is impossible to intro- 
duce it with the finger, and the introduction of the carrier 
causes pain. 

The operations proposed for irritable ulcer or fissure have 
been much discussed. Boyer first pointed out the fact that 
division of the sphincter was at once followed by a complete 
subsidence of the symptoms, and recommended that the in- 
cision should extend through the entire thickness of the 
sphincter. He sometimes went further than this and prac- 
ticed a double division at different points, putting in a large 
bougie and plugging the rectum around with charpie. I have 
known patients that would consent to almost anything for 
relief from an irritable ulcer in the rectum, even to the cut- 
ting through of their sphincter muscles once or half a dozen 
times, if it were necessary for their relief. But, fortunately, 
we have ascertained that it is not necessary to divide the 
muscle at all to procure relief in this affection. Dupuytren 
was the first to modify this operation by making an incision 



IRRITABLE ULCER OR FISSURE. 283 

only through the superficial fibers of the muscle, and I am 
satisfied that if any cutting is done, the manner suggested by 
Dupuytren is the proper method of doing it. Copeland be- 
lieved that an incision through the mucous membrane alone 
was sufficient to cure these cases, but Curling pointed out 
that in the majority of them the ulcer had already penetrated 
the mucous membrane, the fibers of the sphincter muscle 
being frequently visible in the floor of the ulcer. Any one in 
the habit of operating upon these patients has of course ob- 
served that Curling was right. I imagine that Copeland came 
to the conclusion that he did from the fact that, by partially 
dilating the sphincter at the time that he cut the mucous 
membrane, the patient was cured, not by the division, but by 
the divulsion. Dumarquay suggests an operation which con- 
sists of a submucous division of the sphincter ; he passes a 
knife up between the mucous membrane and muscle, and 
divides the latter by subcutaneous division. As it has been 
demonstrated that the division of the muscle is not necessary 
at all to cure these patients, this operation can not be recom- 
mended. In 1829 Recamier offered a substitute for the cut- 
ting operation. His method was as follows : 

"One or two fingers were introduced into the rectum, and 
then, with the thumb outside, the sphincter was pinched up 
and pressed so as to overcome its resistance. This was fre- 
quently repeated in a regular, methodical way, so that no 
portion of the circumference of the anus was allowed to 
escape. " 

Why this method fell into disuse, I imagine, was because 
it engendered the most intense agony. It was done, and it 
had to be performed a number of times ux^on the same pa- 
tient. Conceiving Recamier's idea ; Maisonneuve proposed to 
effect dilatation in a more rapid and thorough manner by 
introducing the fingers one by one, till finally his whole hand 
entered the rectum. When this was accomplished he closed 
his hand and then withdrew it forcibly. There is no doubt 
that this method will accomplish the dilatation of the sphinc- 
ter muscle, but when we consider that it was done without 



284 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

chloroform, the pain that was incident to it being horrible, it 
really looked brutal. Then, when we consider that the sim- 
ple introduction of the hand, especially a large hand, is at- 
tended with great danger, for this reason alone it should be 
ruled out ; and yet the operation has been done in this city 
within the past decade upon a patient who was not anaes- 
thetized. However, Maisonneuve subsequently modified this 
operation into a simple stretching of the anus with the two 
index fingers, under chloroform. But this method also fell 
into disuse, I imagine, for the reason that it did too little, 
just as his other operation did too much. It is singular, how- 
ever, that this idea of dilating the muscle for this trouble 
should fall into disuse, and that the knife should be substi- 
tuted. A comparison of the two methods, I should think, 
would convince any surgeon that the divulsion plan was much 
more satisfactory, and attended with much less evil conse- 
quence than the cutting plan. My method of operating for 
an irritable ulcer, or for fissure, is somewhat different from 
that laid down by the authors. Ball says : " The best prac- 
tice, then, is (if operation is decided upon) to stretch com- 
pletely the sphincter. This is best done by introducing the 
two thumbs into the anus and then separating them forcibly — 
first, in the antero-posterior direction, and then laterally. 
This should be performed quite slowly under an anaesthetic, 
and by degrees the muscle will be felt to yield. The pressure 
should be well under control, to avoid rupture as the result 
of any sudden relaxation of the sphincter. After a few min- 
utes it will be found that the muscle is quite flaccid and has 
lost its tendency to contract." 

Dolbeau, of Paris, is so strongly in favor of forced dilata- 
tion of the sphincter for anal fissure that he scarcely admits 
of any other method. Some authors, in describing this plan 
of dilatation, use the terms " rupture "and "break," as ap- 
plied to the sphincter muscle. Although they do not actu- 
ally mean this, they are bad expressions to use, because stu- 
dents of medicine, especially in their first practice, might do 
some serious harm in this direction. I have said that I be- 



IRRITABLE ULCER OR FISSURE. 285 

lieved the divulsion plan is best. It is an old adage, but nev- 
ertheless true, that experience is the best teacher, and my ex- 
perience has taught me that a simple divulsion of a sphincter 
muscle, without any cutting at all, will cure the vast majority 
of fissures and irritable ulcers. This being true, no risk is 
run. Outside of experience teaching me this, the pathology 
of this form of ulcer leads us to the same conclusion. Gen- 
erally, only a few fibers are involved in this ulceration, and, 
by simply putting them at rest by stretching them, the ulcer 
is made to heal. So well recognized is this that Curling re- 
ports a case where a gentleman came to him from a distant 
point to be operated on for a painful rectal trouble. In 
making the examination, Curling used a speculum in order to 
see the diseased condition. He found an irritable ulcer, and 
set the next day to operate for it. The patient did not re- 
turn, and some weeks afterward wrote Mr. Curling that the 
examination had entirely cured him. There is a moral in 
this story that surgeons might profit by. I have had the 
same thing happen in my practice, which will be observed 
from the following case : 

A gentleman, passing through this city from the East, con- 
sulted one of our local physicians in regard to a pain which 
he described as excessive, occurring after stool. The physi- 
cian suggested that he have me to examine him. We went 
to his hotel and, placing him in a good light on the bed, ex- 
amined him pretty thoroughly externally, but no disease 
could be found. I introduced my finger into the rectum, 
which caused him pain. I then anointed the speculum and 
carefully inserted it, and in opening the blades I saw a recent 
abrasion rapidly give way as the bowel was stretched in the 
effort to open the instrument. I explained to him that he 
had an irritable ulcer, and he remarked to me that he did not 
have time to remain here and be treated for it, but would go 
home and return to this city, if necessary. He wrote me soon 
after that the examination cured him entirely. I should add 
in parenthesis that my bill was not sent to him until I re- 
ceived his letter. 



286 DISEASES OP THE RECTUM, ANUS AND SIGMOID FLEXURE. 

I must say that I prefer, in the vast majority of cases, the 
divulsing plan to the knife, and the following is the method 
that I practice : The bowels should be evacuated, unless we 
should meet an obstinate patient who refuses to do so on ac- 
count of pain. On the morning of the operation the patient 
should be given a large enema of water. When he is anaes- 
thetized I put him into Sims's position, flexing his legs high 
up on the abdomen, elevate his buttocks, and introduce 
a Mathews's speculum. With this I rapidly divulse the 
sphincter and, by closing its blades, change the position of 
the instrument slightly, and again rapidly distend the bowel. 
This I repeat three or four times. It will now be seen that 
the sphincters have lost their contractile force, and the fin- 
gers or thumbs can be easily introduced. I much prefer the 
first three fingers on each hand to the thumbs. They make 
a more gentle pressure and the muscle is more at your com- 
mand. I do no violent pulling in any direction, but, having 
my fingers oiled, I gently pull the muscle, at the same time 
running my fingers entirely around its circumference until I 
feel that it is entirely relaxed. I never break the muscle. I 
frequently say to my class that a good guide as to when the 
operation is complete is to notice the mucous membrane of 
the bowel as it descends over the sphincter muscle nearly to 
its lower margin. I now take a soft sponge, which has been 
dipped in a solution of bichloride of mercury (1 to 3,000), and 
wash the rectum thoroughly out. If I notice any abrasions 
at the margin of the anus that have been produced by the 
stretching, I dust them freely with powdered iodoform. I 
put no dressings whatever on this patient, for the reason that 
I direct the attendant or nurse to sponge the anus often 
with very hot water. This alone quiets pain and it is not 
often necessary to give a hypnotic. The patients' bowels 
should be allowed to move regularly each day, and after the 
movement an injection of carbolized hot water should be 
given. They should be confined to bed for three or four 
days, and at the end of a week, or perhaps a shorter time, 
are able to return to their business. The surgeon should be 



IRRITABLE ULCER OR FISSURE. 287 

very careful in doing the operation of dilatation of the 
sphincters upon women. It will be observed that the sphinc- 
ter muscle in the female yields much more rapidly than in 
the male, therefore much less force is required to accomplish 
the same result. In the phthisical patient, or one enfeebled 
from any cause, especially where emaciation has taken place, 
we should be very careful about stretching the muscle at all. 
In these cases the knife is preferable, if they can not be cured 
by the palliative measures. In my early career as a rectal 
surgeon I thought it necessary to make a free division of the 
sphincter in operating upon these cases, but I have long 
since abandoned the plan, knowing that a much more moder- 
ate operation will do just as well. If, however, for any par- 
ticular reason a deeper incision through the fibers is thought 
necessary, if the anatomy of the rectum will be called to 
mind, it will be seen that an incision can be carried down 
through the median line to the coccyx and yet not divide the 
muscle. My plan of using the knife, however, is simply to 
scarify the ulcer proper, and not to interfere with the mucous 
membrane or any of the tissues that are in a healthy condi- 
tion. I can not understand the necessity of even making a 
division here into the healthy tissues, to say nothing of the 
advice not to divide the sphincter muscle. 

Allingham says : "I think it wise to incise all ulcers situ- 
ated about the internal sphincter, for only by so doing can a 
certain cure be eifected. Here are my reasons : If dilatation 
is employed, the sphincters rapidly recover their power, and 
faecal matter may collect in the ulcer, irritate it again, and 
prevent healing. By a complete division of the external 
sphincter you can obtain a somewhat lengthy paralysis and a 
good drain ; moreover, the ulcer can be easily dressed and be 
made to heal from the bottom." If the distinguished author 
had used the term scarify instead of incise, I would heartily 
agree with him ; but I must submit that I have never yet 
found it necessary to make a complete division of the external 
sphincter muscle in order to cure an irritable ulcer, and it 
must be borne in mind that the division of the muscle might 



288 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

frequently be followed by incontinence of feces. The after- 
treatment of these cases is very simple. The majority of 
such, uncomplicated by other disease, get well with very 
little if any subsequent treatment. But, for fear that the 
ulcer may leave a trace, it is best to direct the patient to take 
an aperient each day for a little time, and to use an injection 
of tepid water into the rectum several times a week. If any 
uneasiness at all exists, the injection of the iodoform and oil, 
as suggested, will meet the indication. 



CHAPTER XIII. 

THE ANATOMY OF THE RECTUM IN RELATION TO THE RE- 

FLEXES. 

There is perhaps no subject occupying the attention of 
the medical profession to-day of more importance than that of 
the reflexes. Surgeons in special practice, in all the depart- 
ments, are giving the subject much study, and the medical 
literature of the day is filled with articles and discussions on 
this very important theme. The field of gynaecology likely 
reveals more evidence of reflex action than any other, yet 
those engaged in treating other portions of the anatomy in a 
special way have found much to interest them in regard to 
the subject under discussion. The oculist, the aurist, the 
genito-urinary surgeon, etc., have discussed the many points 
involved, from their standpoint, and much light has been 
thrown upon a very much neglected field. I have already 
stated in this book that it is sometimes intimated that a spe- 
cialist in any one branch is very likely to refer the patient's 
affection to his field of study, and account for his symptoms 
from such standpoint. I do not believe that the profession is 
so selfish as this. Even granting that there were some who 
would for selfish motives pretend to fix the patient's complaint 
primarily in his own line, and account for the manifestation 
of symptoms by reflex system, it could be easily seen and dem- 
onstrated by one learned in the subject that his premise was 
wrong. These patients, as I have said, are generally referred 
to the specialist, because there are some local manifestation 
or development at the point which falls under the observation 
of this particular one. At the meeting of the Mnth Interna- 
tional Medical Congress, held at Washington, September, 

19 



290 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

1887, I had the honor to read before the Section of Anatomy a 
paper entitled The Anatomy of the Rectum in Relation to 
the Reflexes. Up to that time very little special attention 
had been given to the subject. In dealing with diseases of 
the rectum, it is a matter of every-day occurrence with me 
that such diseases are observed with a history of reflex symp- 
toms. I desire for a moment to refer to reflex disorders in a 
general way, and then to apply the reasoning in a special 
way. Of course there is a varied group of affections which 
fall under this head, but they are being individually consid- 
ered by the different specialists. Therefore, after referring 
to them as a group, I shall apply the principles to localized 
disease in the rectum, and to disease which is supposed to be 
located in the rectum. To have reflex action in any case, we 
must have (a) afferent impressions, resulting from the influ- 
ence of a foreign body, or a pathological state (such as in- 
flammation or ulceration) acting as an irritant upon afferent 
nerves, either in some part of their course or in their periph- 
eric sites of distribution — whether such sites be situated upon 
the external surface of the body or upon some part of one or 
other of the mucous surfaces within the body. Thus it hap- 
pens that the determining cause may in some cases be asso- 
ciated with painful impressions, though in many other in- 
stances such impressions may be more or less completely ab- 
sent. Occasionally mental emotions may take the place of 
peripheric impressions as inciters of abnormal reflex phenom- 
ena. The next essential factor (b) is that the afferent im- 
pressions (painful or non-painful) produced by the irritant or 
pathological state should pass from the nerves conveying 
them through a related nerve center which, from one or other 
cause, chances to be in a state of exalted activity, and thence 
(c) be reflected along one or other set of efferent nerves, so as 
to produce effects of this or that order. As efferent nerves 
are distributed to glands and to muscles (both involuntary 
and voluntary), reflex phenomena may show themselves in one 
or other of the two principal directions : 1. By the modifica- 
tion of the quantity or quality of some secretion. 2. By the 



ANATOMY OF THE RECTUM AND THE REFLEXES. 291 

production of spasmodic contractions in certain muscles, either 
of the involuntary or the voluntary type. 

]S T ow, to illustrate these principles in pathology in a spe- 
cial way, outside of the particular line of which we are speak- 
ing, I will refer to the fact that Dr. George T. Stevens says : 
" Nearly all headaches, neuralgias, almost all cases of chorea, 
and fifty per cent of all cases of epilepsy, are due to incoordi- 
nation of muscles of the eyeball." 

Of course, this is a broad statement and can not be proved 
in its entirety, and yet it goes to show that the subject has 
received very decided attention from this learned man. The 
subject of peripheral nerve irritation is not a new one. 
Every one is aware of the fact that errors of refraction will 
cause headaches. Even the young mother knows that when 
her infant has eaten too heartily it may have a spasm. 
Sayre opened up a wide field for thought and investigation 
when he announced that an adherent prepuce would cause 
spasm in the male child. It is recognized that stricture of 
the urethra may cause many neuroses, and the genital organs 
are responsible for much nervous excitability. And so I might 
go on and recite many instances which would go to prove 
that this subject of reflex action may be considered as a prin- 
ciple in fact, but that it requires much study and careful 
attention sometimes to locate the point from which it starts. 
But as the field in which I work has been much neglected, 
in this matter of reflexes, I simply desire to record here my 
experience and testimony, which will, I trust, enable us to 
gain a point at least in this difficult study. That I may more 
clearly elucidate the subject it will be necessary to recall 
the anatomical bearings of the rectum. The mucous mem- 
brane of the rectum is different from that of any other portion 
of the intestinal tract. It is thicker than that of the colon, 
and just beneath it is found an increased layer of cellular 
tissue which connects it with the muscular layer beneath. In 
this membrane the follicles of Lieberkuhn are freely distrib- 
uted. In structure they are very like the villi of the small 
intestines and covered with the same form of epithelium, and 



292 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

in their walls is a similar arrangement of capillaries. The rec- 
tum receives blood from three different sources. The upper 
part is supplied only by the superior hemorrhoidal, a branch 
from the inferior mesenteric, which also supplies the lower 
part of the colon. The terminal branches of the superior 
hemorrhoidal pass to the lower part of the rectum, but the 
principal blood supply to this part comes from the middle 
and inferior hemorrhoidal, which are primary and second- 
ary branches from the internal iliac, which artery affords 
the principal blood supply to all the pelvic viscera. The 
middle hemorrhoidal is distributed to the pouch of the 
rectum, while the inferior, a branch from the internal pudic, 
passes across the ischio - rectal fossa and reaches the rec- 
tum at its lower part. The internal pudic, besides giving 
a large supply of blood to the rectum, supplies blood to 
the bladder, prostate, vagina, perineum, and external or- 
gans of generation. The veins which return the blood from 
the rectum are numerous. The hemorrhoidal plexus com- 
municates in front with the vesico-prostatic in the male and 
the vaginal plexus in the female. While the inferior and 
middle hemorrhoidal arteries supply the principal part of 
the blood to the lower part of the rectum, the corresponding 
veins return but a small portion of this blood. Almost all 
the blood from the rectum passes through the superior hem- 
orrhoidal vein and into the portal system. The nerve supply 
of the rectum comes from two sources. It receive an abun- 
dant supply from the hypogastric plexus of the sympathetic 
system. In addition to these, we find a supply direct from 
the spinal system of nerves, those to the rectum coming from 
the fourth anterior sacral nerve. This is the only part of the 
intestinal canal which receives branches direct from the spi- 
nal nerves. Therefore the great irritability and sensibility of 
this part can be easily understood. It is a fact that it re- 
quires deeper anesthetization to perform operations upon 
the sphincter muscle than upon the eye ; its nerve supply is 
greater than that of any other muscle of the body, and comes 
from three different sources — from the internal pudic, the 



ANATOMY OF THE RECTUM AND THE REFLEXES. 



293 



fourth sacral, and the posterior sacral nerves. It is a rule in 
the distribution of nerves that the same nerve supplies a mus- 
cle and the integument over it. There is no exception here, 
for they pass in beneath the external sphincter until they 
reach the space between the inner border of this and the in- 
ternal sphincter ; then they divide into two sets of branches, 
ascending and descending. The ascending branches are dis- 
tributed to the mucous membrane, crossing the internal 




Diagram of the nervous relations of irritable ulcer of the anus (Hilton), a, ulcer on sphinc- 
ter ani ; b, filaments of two nerves are exposed on the ulcer, the one a nerve of sensa- 
tion, the other of motion, both attached to the spinal cord, thus constituting an excito- 
motor apparatus ; c, levator ani ; d, transversus perinsei. 

sphincter ; the descending to the integument. The principal 
one of the nerve branches to this part comes from the inter- 
nal pudic, a branch from the lower part of the sacral plexus. 
The pudic nerve is distributed to the muscles and integu- 
ments of the perinseum, to the penis and integument of the 
scrotum in the male, and to the corresponding part in the 
female ; hence the relation and great sympathy between the 
lower rectum and all parts of the perinaeum and external 
organs of generation. The sphincter ani and the sphincter 
urethrse muscles are supplied by the same nerve. We have 
also traced branches from the fourth sacral to the bladder, 
prostate, and vagina. Tracing all these nerves to their origin, 
we find that the spinal nerves supplying all the pelvic viscera, 
all the structures forming the peringeum and external organs of 
generation, are given off from the same point in the spina] cord. 
Hence it is easy to understand that the rectum is a great 
power in the local reflexes, and can be irritated in return. 



294 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

Because of the abundant blood supply of the rectum, it is nat- 
ural that in the exercise of its peculiar office its blood-vessels 
should often be in a state of congestion, and this alone excites 
to reflex action, and constipation is a great breeder of disease 
for this reason. As a result, we frequently find in women re- 
flexes, producing pain in the bladder, mouth of the urethra, 
womb, back, thighs, ovaries, vagina, perinaeum, etc. In the 
male, pain in the bladder, penis, urethra, scrotum, prostate, 
etc. Many of these troubles are directly traceable to the rec- 
tum as their source, and yet this fact is often overlooked. The 
relation of the rectum with the peritonaeum is so close that ab- 
dominal pain is but a reflex from these parts. The meso-rec- 
tum, dipping as it does within a finger's length of the outlet, 
is contiguous enough to take on inflammatory action from 
many conditions that may exist in the rectum. I have had 
occasion to point out, for this reason, the dangers that might 
arise from injecting internal haemorrhoids with carbolic acid. 
We have seen how easy it is for the rectum to become con- 
gested, because of its vast blood supply and dependent po- 
sition. Being equally supplied with nerves, this congested 
state causes great reflex action. It is my observation that 
when the rectum is congested, from whatever cause, the dis- 
charge of mucus is taken as indicating more trouble than 
really exists. Charlatans are in the habit of parading these 
symptoms as of the gravest importance, and many fall into 
the trap. The reflexes from this congested condition of the 
rectum are often shown upon the womb and its appendages. 

Case.— A lady, aged twenty-four, married, was referred 
to me by a gynaecologist. History : She had complained 
for many months with backache, pains down the thighs, gen- 
eral lassitude, melancholia, a bearing-down sensation in both 
the vagina and rectum, pain over the seat of both ovaries, con- 
stipated habit, leucorrhcea, loss of flesh, irregular menstru- 
ation, difficult micturition, and a slight discharge of mucus 
from the bowel. Upon an examination of the womb and its 
appendages by the gynaecologist, there had not been enough 
trouble found to account for her symptoms. He treated her 



ANATOMY OF THE RECTUM AND THE REFLEXES. 295 

for several months, however, and, her case not clearing up, he 
advised her to consult me. Upon examining the rectum with 
a speculum, I found it highly congested, very red and sen- 
sitive, and a film of mucus covered the entire circumference 
of the gut for several inches up. The cause for this extensive 
congestion was not discernible. I was satisfied, however, that 
all the symptoms mentioned were purely reflex from the rec- 
tum, and proceeded to treat her. Hot- water injections were 
ordered to be taken twice daily for several days, after which 
the entire portion of the congested gut was brushed over with 
a fort y-per- cent solution of nitrate of silver. After three or 
four days I had her inject into the rectum fluid Jiydrastis 
and water, equal parts, throwing in about one ounce each 
time. The solution was gradually increased until the pure 
liquid Jiydrastis was used. The redness of the mucous 
membrane and all pain gradually disappeared, the discharge 
ceased, and all reflex trouble vanished. 

To have a reflex act there are three things necessary : 1, 
an afferent nerve-fiber ; 2, a transferring center ; 3, an efferent 
nerve-fiber, forming a reflex arc. From the nerve supply of 
the rectum it can be easily seen that pain would be manifest 
over the sacrum and coccyx in rectal disease. If the disease 
is limited to the lower part of the rectum the patient will 
complain of pain at the end of the coccyx ; if the disease is in 
the central part of the rectum, the pain will be in the center 
or lower part of the sacrum ; and when the disease is in the 
upper part of the rectum, the reflex will be in the upper 
part of the sacrum, the innominate arch. The location of 
the reflex, therefore, will indicate the part of the rectum in- 
volved, demonstrating that the nerves to any part of the rec- 
tum, and to the posterior surface of the vertebral column op- 
posite these, are given off from the same point in the spinal 
cord, bearing the same relation as the nerves to a muscle and 
the skin over it. Therefore I would call attention to the fact 
that the rectum having a nerve supply direct from the spinal 
system, through the fourth anterior sacral nerve, it is often 
the case that a diseased rectum, by reflex to the cord, may 



296 DISEASES OF THE RECTUM, A.NUS, AND SIGMOID FLEXURE. 

give symptoms simulating grave trouble of the same. The 
following case will illustrate this fact : 

Case I. — An army officer was referred to me for examina- 
tion and treatment of a large rectal prolapse. He was then 
under treatment for supposed locomotor ataxia. Upon ques- 
tioning him concerning his general condition, the following 
symptoms and history were elicited : Pain in both legs, with 
a decided unsteady gait ; great nervousness, weakness of 
both legs, loss of sexual power, persistent constipation, 
heavy bearing-down pain in the rectum, numbness in feet 
and legs, melancholia, and general restlessness. Upon forc- 
ing out the rectum after an enema, a very large prolapse 
was discovered, which had existed for many years. Taking 
the diagnosis of ataxia as correct, I could not promise him 
much from the operation for prolapse, except to free him 
from the inconvenience of the protruding mass. The opera- 
tion was done, however, and as the wounds healed, all symp- 
toms here described began io gradually disappear. After two 
months he pronounced himself cured of all trouble— rectal, 
spinal, vie. Be now walks a steady gait and great distances, 
bowels regular, sexual appetite and capacity returned, no 
pains or numbness in legs, and he expresses himself as being- 
alt oget her a different man. It was clearly shown by the oper- 
ation that the whole train of symptoms was reflected from 
the rectum. The chief nerve supply is to the lower part of 
the rectum, hence it is that we get some very decided retiexes 
by having this portion of the gut diseased. 

("ask IT. — Mr. J. C. II., aged thirty, a commercial traveller 
by occupation, came io consult me about an uneasy condition 
of his rectum, lie said that there was no special pain, but 
that he felt a general uneasiness, not only in the rectum, but 
in all the contiguous parts. In the perineum was a sense of 
weight, the action o\' the bladder was sometimes interfered 
with, frequently had pain in the urethra, his back often 
ached, and he would frequently sit down to get relief from 
these symptoms. lb^ said that they were aggravated to a cer- 
tain degree by the act of defecation, and that for this reason 



ANATOMY OF THE RECTUM AND THE REFLEXES. 297 

divuJsion of the sphincter muscle had been practiced in his 
case three distinct times by three different surgeons, and that 
for a while he would feel somewhat relieved, but after a little 
time the old sensations would come back. I examined him 
carefully, and detected two small ulcers situated on the left 
side of the bowel, just above the internal sphincter muscle. 
Dorsally located was a fibrous structure which felt, to the 
finger, as cicatricial tissue. I did not use a probe, expecting 
to do so later. I said to him that, in the majority of such 
cases, the divulsion plan was usually practiced, but that in 
his case I thought the knife would have to be used in con- 
junction with the divulsion before a cure was effected. He 
was put under chloroform, when I forcibly divulsed the 
sphincter muscles and scarified the ulceration. I then took 
a probe, and, inserting it over the hard tissue, I discovered a 
small sinus beginning therein and running up the mucous 
membrane about one inch. I laid this freely open. After 
recovering from the effects of tin; operation the patient no 
longer complained of any of the reflex symptoms. 

Case III. — Mr. M., a prominent merchant, was brought 
by his family physician for the purpose of consulting me 
in regard to some rectal complication. The physician re- 
garded his stomach as the objective seat of trouble, but he 
said that latterly he had complained of an uneasy sensation 
in his rectum, together with his other symptoms, and that he 
desired to have it investigated. He gave the following his- 
tory : About five years before he had begun to feel bad in a 
general way. He imagined that he had dyspepsia or indiges- 
tion because of abdominal pains, from which he frequently 
suffered. Although he could not say that these pains were 
connected or had any relation with his eating, yet he im- 
agined that certain articles of food disagreed with him. He 
was so pronounced in this opinion that his physician had 
dieted him for several years, (lining which time he had lost a 
great deal of flesh, and had quit business. In conjunction 
with the abdominal pains, ho also suffered pain in the back 
and was easily fatigued. His bladder was disturbed and the 



298 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

organs of generation influenced. He expressed himself as 
being impotent at the time. The patient himself believed 
that he had more serious trouble in the rectum than his phy- 
sician suspected. Being comparatively a young man, with 
no organic disease that could be found, I thought that most 
of his trouble was possibly reflex, and that the difficulty 
would likely be to locate the source of irritation. He was 
given some preparatory treatment in the way of clearing out 
the alimentary tract and washing out the rectum, when he 
was placed upon an examining table, and by the aid of a 
speculum and the electrical search light, the rectum was 
examined thoroughly. The lower portion of the bowel was 
free from any special change ; but about Hye inches above 
the external sphincter muscle the gut was denuded of its 
epithelium for a considerable space, and the mucous mem- 
brane underneath looked red and angry, and was evidently 
thickened. I could not detect any pus upon the surface, but 
a large amount of mucus fell into the speculum and had to 
be wiped away. I brushed the entire abraded surface with 
pure carbolic acid, and then coated it over with oil contain- 
ing iodoform. I put the patient to bed, gave him a spe- 
cial diet for some time, and medicated the rectum by mild 
local applications, until the redness had disappeared and the 
reflexes had gradually vanished. At the end of three weeks 
he accompanied me to a restaurant, where a full meal was or- 
dered, embracing especially those things which had been for- 
bidden him, and I asked him to eat heartily of each and every 
article. This he did without reserve, and suffered no incon- 
venience whatever from the meal. I discharged him as cured, 
and he returned to business, gained ffesh, and was happy. 

Case IV. — Dr. D., aged forty-eight, gave a history of 
dyspepsia in an aggravated form. In narrating his own case 
he said that for a number of years he had been unable to 
take solid food, and had limited his diet to the fluids. Upon 
different occasions he had tried to eat something more sub- 
stantial, but each time had paid a fearful penalty, in that 
such pains were excited in the stomach and intestines as to 



ANATOMY OF THE RECTUM AND THE REFLEXES. 299 

put him to bed. One prominent symptom in his case was 
gaseous distention, and frequently he was enabled to trace 
the route of the pain through the transverse into the descend- 
ing colon, and imagined often that it located itself in the sig- 
moid flexure. But there was such a sense of uneasiness in 
the rectum, attended with a great discharge of mucus, that 
he consulted me. I examined the abdomen carefully by pal- 
pation, etc., but could detect no morbid growth. I therefore 
gave the rectum a rigid examination. Inserting a long tubu- 
lar speculum and withdrawing the guide, it could be seen 
that the upper part of the gut was intensely congested, and 
discharged mucus freely. I gave a diagnosis of an existing 
proctitis, and the opinion that this inflammatory trouble ex- 
tended to the mucus membrane of the entire colon. I there- 
fore suggested that he take a systematic course of treatment 
for the trouble. As he had complained of constipation, I 
put him upon a brisk aperient treatment for three or four 
days. Then confining him to his bed, I proceeded to treat 
him in the following manner : Having him assume the Sims 
position with the buttocks elevated, so as to throw the ab- 
dominal contents forward, I introduced a No. 5 Wales rectal 
bougie fully into the sigmoid flexure. Through this I in- 
jected the fluid extract of Pinus canadensis, a desertspoon- 
f ill to two ounces of water. This I repeated each day for a 
week. JSTot getting the benefit I desired, I substituted fluid 
7iydrastis, and preceded the injection by throwing into the 
sigmoid from a quart to half a gallon of hot water. This 
was allowed to remain until by a natural inclination it was 
passed off. The fluid Hydrastis, diluted with four parts of 
water, was then deposited in the sigmoid flexure. In conjunc- 
tion with this local treatment I had him take thirty drops of 
the fluid Hydrastis in half a cup of water three or four 
times a day. His diet was of fluids only. After the lapse 
of eight or ten days he expressed the opinion that he was 
materially better. The reflected pains had disappeared, and 
the mucous discharge so materially lessened as to be scarcely 
perceptible. Being a physician, he learned to introduce the 



300 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

instrument himself, and I advised him to keep np the treat- 
ment, injecting every other day, instead of daily, for an in- 
definite time. I saw him again after the lapse of several 
months, when he told me that he had gained flesh, and was 
able to take some solid food, although certain articles of diet 
still disagreed with him ; that he had not observed any mucus, 
and, although not absolutely well, was very greatly improved. 

This case evidences the fact that patients are sometimes 
treated for dyspepsia with the stomach as the objective 
point, when in reality the indigestion is referable to the in- 
testinal tract. The reflected pains that this man suffered 
started, I am sure, and were kept up, from the rectal irrita- 
tion. As soon as the proctitis began to disappear and the 
mucous membrane of the rectum grew paler, the reflex symp- 
toms diminished. 

Case V. — Mr. S. B. B., aged twenty-six, in appearance a 
stout, robust, healthy man, about five feet eleven inches tall, 
and weighing one hundred and sixty pounds, slightly inclined 
to embonpoint. This man had passed through the hands of 
a number of regular practitioners and several specialists, and 
was at last referred to me. He detailed his own case in about 
these words : " I get no sympathy for the pain I suffer, be- 
cause, as you observe, I look perfectly healthy. I have tried 
to persuade my own mind that my distress is purely imagi- 
nary, but I am in such a condition that unless I get relief I 
am certain I will have to abandon my business. My distress 
consists in a constant pain in the back and down the thighs. 
My rectum feels as if it is never really unloaded, and there is 
distressing, gnawing, aching pain there always. Sometimes 
this pain is aggravated by the act of defecation, but usually 
it is not. My bladder acts irregularly, and oftentimes with 
pain. To sum it up, every organ that I have below my waist 
seems to be affected, and I have consulted a number of physi- 
cians and several specialists, the last one being a genito-uri- 
nary surgeon, who suspected that I had a stricture, but at last 
concluded that I did not, and referred me to you." 

I asked him about any discharge from the rectum, and he 



ANATOMY OF THE RECTUM AND THE REFLEXES. 301 

said there was some mucus, but not a great deal. No pus, 
that he had ever detected, and only a drop or two of mixed 
blood, occasionally. I examined the rectum with my finger 
first and found one sensitive spot. The prostate was a little 
enlarged, but not much above normal ; slightly sensitive, but 
not acutely so. The sphincter muscle was spasmodic. I sug- 
gested the operation of at least divulsing the sphincter mus- 
cle, and while doing so to search for any other trouble. To 
this he consented, and the next day he was put under the 
effect of chloroform, when I freely divulsed the sphincter 
muscles, but could not find any particular disease. For sev- 
eral weeks he expressed himself as being greatly relieved, 
after which the same pains came back. Supposing that this 
was a case of neuralgia of the rectum, I suggested that he try 
a thorough course ot electricity, and referred him to a com- 
petent man. It was used on him for several months with no 
appreciable effect. I had him again consult a genito-urinary 
surgeon, who for several weeks passed every alternate day 
a good-sized sound into the patient's urethra. The reflexes 
were again thoroughly established, and he came back to me. 
This man referred his trouble either to his prostate or to his 
rectum — he was unable to decide which — and I must confess 
that I was just as unable to decide the question as he. I 
asked him to lie on the table and let me make another exami- 
nation of his rectum When I reached this sensitive spot, 
which was dorsally situated, he complained of pain. Keep- 
ing my finger upon the spot, I took a long probe, and, insert- 
ing it alongside my finger until it reached this particular 
place, I searched for a little time for any opening that might 
exist. At last my search was rewarded by the probe slip- 
ping into a sinus, which ran up the mucous membrane at 
least one inch. Whether this sinus had developed since I 
first examined him, or whether I had overlooked it in the be- 
ginning, I am scarcely able to say. Anyway, I asked him to 
take an anaesthetic again, so that I might divide it. He 
readily agreed to this, and, being anaesthetized the second 
time, I divulsed the muscles again, and, putting a small 



302 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

grooved director through the sinus, slit it up. Not being con- 
tent with this, I applied pure carbolic acid to the tract. He 
remained in bed a week, then came to my office and told me 
that he was satisfied that we had at last struck the right 
place. He improved from that day, and, although he came 
back to see me several times, he never complained of the re- 
flexes. This case, I am sure, would have been classed by 
some as purely neuralgic. In looking through the speculum, 
no trace of the opening or sinus could be seen, and even an 
expert finger could not detect it. Of course it can not be 
denied that all the reflex symptoms were due to this one local 
point, as they cleared up after dividing the sinus. 

Case VI. — Dr. W. S., aged thirty-two, apparently in good 
health but of a nervous disposition, lived in a country town 
and had a large practice. He gave this history : That for 
many years he had had a highly colored and scanty condition 
of the urine, which burned him at the act of passing ; that 
for several years he had thought he had a urethral stricture, 
at least had been treated for such ; believed that his prostate 
was hypertrophied, and that in consequence he had a burning 
sensation in the rectum, but in addition to this had consider- 
able pain during the act of defecation and for several hours 
afterward. He thought that a free divulsion of the sphincter 
muscle would do him good. I examined him per rectum, 
found his prostate somewhat enlarged and sensitive, and the 
surrounding mucous membrane slightly congested. There 
were several sensitive spots in the lower rectum but no dis 
tinct ulceration. He took chloroform, and I dilated the 
muscle forcibly. He returned home in a few days, and wrote 
me at the eud of two weeks that he was materially improved. 
After the lapse of six or eight months he came back, com- 
plaining very much as he did before, and insisted upon an- 
other dilatation of the sphincter. This was done under pro- 
test, because I believed that his trouble was reflected to the 
rectum, and not from it. At the same time that I divulsed the 
muscle I cut through some of the muscular fibers, but told 
him before he returned home that he might be temporarily 



ANATOMY OF THE RECTUM AND THE REFLEXES. 303 

improved by this course of treatment, but that I did not 
believe it would be a radical cure, and suggested that his 
prostate was to blame. Several months after returning home 
he wrote me the following: "I write you this morning to 
give you the result of the operation you performed on my 
rectum some months ago. The operation was of great benefit 
to me, but, as you foresaw, would not and has not cured me 
entirely of my rectal trouble. However, I am materially 
better than when you saw me. I have no aching after stool, 
and most of the time I have no uneasiness or feeling of dis- 
comfort. I have lost that sensation of rawness and burning 
at the sphincter. I am as strong sexually as I ever was, and 
have no pain during sexual intercourse ; on the contrary, I 
feel better for about twenty-four hours afterward. I have 
been riding in the saddle, nearly ever since I returned home, 
an average of twenty to twenty-five miles per day. The riding 
at first seemed to do me good, but during the last two or 
three days has produced a feeling of soreness in the peri- 
nseum. I am of the opinion that all the trouble that I now 
have in the rectum is from the prostate, although I have no 
discharge whatever from the urethra, and but slight tender- 
ness on pressure per rectum. My urine for twenty years has 
been high-colored, scanty, and producing a burning and hot 
sensation during the act of urination." 

It will be seen by studying this case that there was a com- 
bination of circumstances to be considered in its treatment. 
The gentleman had had some bladder disturbance for twenty 
years. For a number of years he had recognized a prostatic en- 
largement, although a young man. The loss of power in the 
act of coition, together with many other symptoms, pointed 
clearly to a stricture of the urethra. It will be observed that 
he states in his letter that that power was restored by the 
operation which I did upon his rectum, though this may 
be purely imaginative. My idea is that by stretching the 
sphincter muscle, tension of the parts was overcome, and that 
as long as the relaxation exists he does not feel the reflexes 
perceptibly. The sphincter, which is always spasmodic with 



304 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

him, loses this spasm by divulsion, and whereas he is bene- 
fited by this plan of treatment, it simply lulls him into the 
belief that he is cured. May it not be that a stricture of 
large caliber exists in the urethra, and until that is eradi- 
cated he will suffer the symptoms of which he complains ? 

The two cases which are to follow will very beautifully 
illustrate this special point, and will also explain the diffi- 
culty in making up a diagnosis. 

Case VII. — A distinguished genito-urinary surgeon of 
this city met, in traveling, a Western physician, who said to 
him that he had great irritability of the sphincter muscle, 
attended with a great deal of pain, not connected, however, 
with the act of defecation. The surgeon advised him to come 
to me for treatment, which he did. Upon questioning him, I 
was satisfied that the rectum was not the locality for the 
reflex, but gave him a careful examination, and, as far as the 
rectum proper was concerned, found no trouble. But when 
I touched the prostate I found it so sensitive as to elicit a 
cry of pain from him. Being satisfied that this was the point 
from which the reflex to the rectum came, I advised him to 
be examined and treated by the genito-urinary surgeon who 
was so kind as to refer him to me. 

Case VIII. — The next case was very similar in several 
particulars. A genito-urinary surgeon, living in one of the 
large cities, consulted me in regard to himself. He said that 
for several years he had been annoyed by a constant feeling 
of distress in the rectum ; that it was just sufficient to keep 
him uneasy. Outside of passing mucus he had no dis- 
charge from the rectum, and the pain was not aggravated 
by defecation. He had consulted some surgeon in his own 
city some months ago, and he had removed from the rectum 
two haemorrhoids, but, from the description, they must have 
been insignificant in size. The operation had not in the 
least lessened his trouble. I examined him with the finger, 
and immediately detected a large and sensitive prostate. Of 
course, under the circumstances, I could only say: " Physi- 
cian, heal thyself." 



ANATOMY OF THE RECTUM AND THE REFLEXES. 305 

Case IX. — A lady, thirty years of age, of fine physique 
and good family history, was sent to me with the following 
symptoms : A constant burning, lancinating pain over the 
left lumbar region. This was her main distress, though she 
complained of pain in the rectum, with a discharge of mu- 
cus and pus. An examination revealed that she had an 
internal fistula, which began just within the anus, extend- 
ing around the gut to a considerable depth. She was an- 
esthetized, and the operation done according to the rules 
laid down. She improved materially, having only occasion- 
ally severe pains in her back. When she first came to me 
she was able to walk scarcely at all. After a little while 
she could walk a number of squares without fatigue. As the 
wound healed, the pain only occurred at intervals, until at last 
she had attacks of severe pain, though not constant, just as 
severe as originally. Although now she has distinct exacer- 
bations from pain, she still, at the present writing, has at 
times a very terrible distress in the same spot that she did 
before the operation. This good woman has no neuralgia of 
the rectum, but she certainly has neuralgic pain in the region 
referred to, which evidently originates in the rectum. The 
question is, if the fistulous tract produced this pain, as it un- 
questionably did, why is it, after the eradication of the fistula, 
that she still suffers just as severely, and only at intervals ? 
Can it be that a nerve is still embraced, perhaps in the cica- 
trix, or is it that the nerve took on inflammatory action a 
good while ago, . and is still so affected ? 

Case X.— Mr. H., a prominent banker of this city, was 
seen by me under the following circumstances : He had been 
an invalid for about one year. During the early part of his 
illness he had consulted an itinerent physician in regard to 
some hemorrhoidal trouble, and was treated by him, I think, 
by the carbolic-acid plan of injection. Some time after this 
his health began to fail, he lost flesh and energy, and com- 
plained of erratic pains. His natural disposition was a nerv- 
ous one, but he was a very energetic man. He continued to 

lose flesh and his nature was radically changed. It was pro- 
20 



306 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

nounced by several physicians who saw him that he had ma- 
lignant disease, but the exact location was never defined. 
Being a prominent man, it was circulated through the press 
that he was in a dying condition, and upon several occa- 
sions he bid his friends good-by with the belief that he would 
never get well. About this time I was called in consulta- 
tion with one of his surgeons. Visiting him one afternoon, 
we found him sitting in a large chair on his front porch. 
As we approached him, he looked to me as a man that 
could not live long. He was very feeble, pale, emaciated, 
and melancholy. He asked us to be seated while he detailed 
to us his case. It was not my desire to know anything of 
his former treatment, or any opinions of his case that had 
been expressed by others. I simply wished to know what 
his symptoms and condition were at the present time. He 
was scarcely able to finish a recitation of his case. Between 
his sentences he would stop to rest, and I suppose that he 
occupied fully three quarters of an hour in telling us his 
condition. He said that he had sent for me because of a 
rectal complication that was not only giving him great pain, 
but was rapidly exhausting him ; that the greatest distress 
with which he now suffered was pain during and after the act 
of defecation ; that he had then, and had had for some time, 
a distressing diarrhoea, that could not be controlled by medi- 
cines ; that each and every time his bowels moved the pain 
was so great that he could scarcely bear it, and he stated 
again the fact that between the diarrhoea and the pain he 
was rapidly going down. He also remarked to me that he 
did not have long to live, and the principal reason for send- 
ing for me was to know if I could do anything for him that 
would let him down to his grave in peace. After he fin- 
ished this recital his attending physician and myself, aided 
by a negro servant, helped him through the hall into his 
room and on to his bed. I told them that I desired to 
examine his rectum with my finger. He said he dreaded 
this from the fact that it would cause him great pain. As- 
suring him that I would be as gentle as I could, I anoint- 



ANATOMY OF THE RECTUM AND THE REFLEXES. 307 

ed my finger and passed it into the rectum. I found great 
resistance from the sphincter muscle, which was hypertro- 
phied, very irritable, and spasmodic. In getting my finger 
well into the rectum, and sweeping it around the upper edge 
of the sphincter, I detected a well-defined ulceration ex- 
tending around the circumference of the gut. I then with- 
drew my finger, when he asked me if I was through. I in- 
formed him that I was, and that I did not desire to use the 
speculum, because it would give him great pain, and could 
reveal no more than my finger had. He then said : ' ' What 
is your verdict % Can you do anything for me?" adding : " I 
want you and the doctor here to tell me plainly to my face, as 
it is not necessary for you to go out of the room." I then 
said to the physician: "I suggest that the patient be put 
under an anaesthetic, and that we practice forcible divulsion 
of the muscle, and do for the ulceration what we can." His 
physician readily acquiesced in this, and, turning to the pa- 
tient, explained what we intended to do. He asked us if we 
expected to do it then. We replied that at that hour it was 
too dark, and that we would come out the next morning 
before breakfast and do the operation. Both his physician 
and myself said to him that in his present condition there 
was danger in giving him the anaesthetic, but that the op- 
eration could not be done without it. He turned to me and 
said : " Can you tell me, if I should die on the table, will 
such a death invalidate my life policies ? " His physician 
and myself replied that we had no idea that it would invali- 
date them. He said : " All right, gentlemen, come out in the 
morning and I will be prepared for you." During this conver- 
sation the point was brought out that, notwithstanding his en- 
feebled condition, the terrible pain, and mental distress over 
the idea that he would not live long, he had a splendid appe- 
tite and indulged it, adding that he frequently would lie 
awake at night thinking with pleasure what he would eat 
for breakfast. After directing that he leave off his morning 
meal, we said that we would come out to his residence and 
eat breakfast. We then left the room, and his daughter, fol- 



308 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

lowing, accosted me and said : " What do you think of my 
father % " I replied that I thought him in a very serious con- 
dition. She informed me that there had been many opinions 
given in his case, and that several eminent physicians had 
pronounced his disease cancer, but did not seem to know 
where it was, and asked me what I thought about it. I said 
in reply : ' ' From his appearance and present condition, I must 
say that I also believe that he has a cancerous disease." My 
reason for giving this opinion was — first, I had heard and read 
of this case for a number of months. It had been firmly im- 
pressed upon my mind that the belief of the physicians who 
had seen him prior to me was that he was dying of malig- 
nant disease. Second, when I saw him he looked to me very 
much like a man who had been reduced to the state in which 
I found him from such disease. He was greatly emaciated, 
of bad color, wonderfully exhausted, suffered from a diar- 
rhoea and an exaggerated pain. It never occurred to me 
that the ulceration in his rectum had been overlooked as 
a factor, if not the great factor, in his case, that had brought 
him to his deplorable condition. The next morning, a little 
after sunrise, his physician and myself drove out to the resi- 
dence and found the patient ready for the operation. He 
expressed no fear about the consequences, but was in rather a 
cheerful mood and desired us to proceed. His attending phy- 
sician gave him the anesthetic, of which he took quite a good 
deal. When fully under its influence I drew him into Sims 
position, anointed my two thumbs, and slipping them into 
the rectum, I hooked them over the sphincter muscle. When 
I made an effort to divulse it I found it a difficult job to do. 
It had great resisting power because of its indurated and hy- 
pertrophied condition ; so, after divulsing it to a certain ex- 
tent with my thumbs, I introduced the three first fingers of 
each hand, and it required all the force that I could command 
to break down the resistance. This was, however, done, and 
then I took my two first fingers of the right hand and thor- 
oughly rubbed and scraped the ulceration all around the cir- 
cumference of the gut until it became smooth and bled freely. 



ANATOMY OF THE RECTUM AND THE REFLEXES. 309 

We then irrigated the rectum, and allowed him to come from 
under the influence of the anaesthetic. I did not see him again 
for some time, but was informed that he was doing well and 
apparently improving. After several weeks he was enabled 
to walk around his house and out on his lawn. At the end 
of sixteen days I visited him with his physician. He told me 
that there had been a grand improvement ; that he had his 
actions in comparative ease, and that in the sixteen days he 
had only had eighteen actions, whereas, before the operation, 
he had had the diarrhoea of which he had spoken. After a lit- 
tle while more he was driven into the city to his place of busi- 
ness, where he would remain for a time and return to his home 
for rest. The reflected pains gradually disappeared, he took 
on flesh, and after a few weeks resumed his business at his 
bank, having fully recovered from his malignant (?) disease. 

This case speaks for itself. That his whole train of symp- 
toms was due to this irritable ulceration in his rectum I do 
not think any fair-minded man can doubt. I am also satisfied 
that if the operation had not been done he would be in his 
grave now. I must also admit in the report of his case that 
I shared the opinion that the other physicians had given, 
that his trouble was malignant. Therefore I simply have to 
say that as far as that opinion was concerned it was a mis- 
take. However, I have the satisfaction of knowing that I 
did the operation which saved his life, and was warranted in 
so doing. It must be conceded that had this man died un- 
der the effect of the anaesthetic, I would have been censured 
for advising it; but my own conscience would have been 
clear in such event, although such a termination would have 
hurt me in many ways. I think the case demonstrates, too, 
that the power of the reflexes is of most wonderful concern 
in disease, and that it is a study worthy of our attention. 
Sometimes great operations result in but Utile good. In this 
instance a small operation resulted in great good. 

Ball says, in his admirable book on The Diseases of the 
Rectum and the Anus, in regard to this particular operation 
and its results, that "in the whole range of surgery there 



310 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

are but few diseases which, while of a very limited extent, 
produce such extreme misery to the patient, and none in 
which surgical treatment is attended with more certain suc- 
cess, than in the affection under consideration — viz., irritable 
ulceration of the rectum." 

Cripps says : " The symptoms to which an anal ulcer gives 
rise are especially painful and distressing to the patient, but 
it is within the power of surgery to afford complete and per- 
manent relief by the simplest operative procedure. I have 
known a strong and otherwise healthy man practically inca- 
pacitated for business from one of these ulcers no larger 
than a threepenny-piece." 

Allingham says: " The disease, irritable ulcer of the rec- 
tum, wears out the patient's health and strength in a remark- 
able manner. The constant pain and irritation to the nervous 
system are more than most persons can bear. I have fre- 
quently seen women suffering from a small anal ulcer who 
thought they must have cancer in consequence of their ex- 
treme illness and pain. What, under these circumstances, is 
very extraordinary, is the length of time people go on endur- 
ing the malady without having anything done for it. I have 
known patients who for hours could not bear to stir from one 
position, the least movement causing an exacerbation of the 
pain ; it often continues very severe, and of a burning char- 
acter, or it is of a dull, heavy character, and accompanied by 
throbbing which lasts for hours, sometimes even all day, so 
that the patient is obliged to lie down and is utterly incapable 
of attending to any business." 

In explanation of this terrible pain that patients suffer, 
Allingham says: "The lower part of the rectum, and the 
anus, are very fully supplied by branches of nerves from the 
sacral plexus, and more especially from the pudic. These 
nerves send numerous branches between the fibers of the 
sphincters, and immediately beneath the mucous membrane ; 
thus very superficial ulceration exposes a nerve, and the 
slightest touch or contraction of the sphincter causes intense 
pain." 



ANATOMY OF THE RECTUM AND THE REFLEXES. 3H 

Every author who has written upon the subject of rectal 
diseases has called attention to the fact that an irritable ul- 
ceration of the rectum is the most painful and distressing of 
all rectal affections. Many of them have mentioned that, be- 
cause of the great pain and the numerous reflexes incident to 
the disease, it has often been mistaken for cancer. Unrecog- 
nized, it goes on until the patient is so exhausted and dis- 
tressed that life is a burden to him. 

Case XI. — Mrs. Y., a young widow, was sent to me from 
an interior town in Kentucky, conveying a note from her 
family physician stating that she had been an invalid for 
several years and had been treated in a general way for many 
complaints, and had been in the hands of a gynaecologist for 
womb disease, had received treatment from a neurologist 
for nerve exhaustion, and added that the lady was very in- 
telligent and would detail her own case. She stated in sub- 
stance about this : That for many years she had been of a 
constipated habit, for which she had taken many drugs ; that 
about two years ago she began to suffer pain in her abdo- 
men, her back, and her thighs, and also mentioned that she 
believed that she had heart trouble. I desire to state in this 
connection that a disturbed heart action is a reflex which we 
sometimes see with disease of the rectum, especially of its 
upper part, for an irritation of the rectum will inhibit the 
action of the heart. This is very clearly shown when the 
patient is under anaesthesia and the sphincter muscles are 
divulsed ; it is very common for the pulse to become quite 
weak. She had been told that these symptoms indicated 
womb trouble, and she had been sent to a specialist to be 
treated for it ; that he had told her that her womb was dis- 
placed, but that there was no special disease there. She said 
that about two years ago she began to pass some mucus 
from the bowel, but paid very little attention to it until she 
began to be attacked with a morning diarrhoea, which con- 
sisted principally of a discharge of mucus. She said, how- 
ever, that she would have one daily evacuation, normal in 
amount and consistence. At last she began to realize that, 



312 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

just before and during the act of defecation, she felt worse ; 
not that any acute pain was caused by it, nor did she refer 
the uneasiness to the lower part of the rectum, but said that 
whenever she felt a desire to go to stool there was a " sicken- 
ing " pain all through the bowels, and after the bowel had 
acted she frequently felt nauseated and faint. She had lost 
some flesh, had become nervous and fretful, and regarded 
her malady as a serious one. I had her rectum thoroughly 
cleansed by an enema, after she had taken a purgative, and I 
submitted her to an examination with the speculum. [In this 
connection I would say to those who do not possess a special 
set of speculums, that if they will take an ordinary six-inch 
gutta-percha speculum and insert through it a Wales's rectal 
bougie, and have the point of the bougie to extend about two 
inches through the instrument at the furthest extremity, then 
anoint the instrument and the portion of the bougie that is 
shown, insert into the rectum, and then withdraw the bougie, 
a good view of the gut can be had for six inches. The bougie 
acts as a guide for the speculum, and enables it to be intro- 
duced beyond the sphincter. However, a set of Cook's 
tubular rectum speculums can be procured from William 
Armstrong & Co., Indianapolis, for a small price.] 

Having inserted a tubular speculum to the extent of six 
inches, and withdrawing the guide, it could be easily seen 
that the upper portion of the rectum was in an inflammatory 
state. Situated dorsally was a well-defined but small ulcer, 
very sensitive to the touch. I coated this ulcer with lunar 
caustic and withdrew the speculum. I had this patient go 
to bed, assume the recumbent position, and partake of a 
liquid diet only. On the third day I examined the bowel 
again, and made an application to the inflamed surface of one 
part of campho-plienique to twenty parts of water. Allowing 
her to rest for two days, I had the nurse to begin an injection 
of sweet-almond oil, one ounce ; iodoform, five grains ; subni- 
trate of bismuth, twenty grains— this amount to be thrown 
into the bowel through the longer tube of a Davidson syringe, 
the patient being on the left side, with the pelvis elevated. 



ANATOMY OF THE RECTUM AND THE REFLEXES. 313 

In two weeks' time she was materially improved, and at the 
expiration of one month went home cured. 

Case XII. — A lady, about forty years of age, was sent to 
me by the late Dr. E. D. Foree for an examination. She gave 
a remarkable history. She said that five years before she 
weighed one hundred and sixty pounds ; that in the five years 
she had lost sixty pounds, weighing at the time she consulted 
me only one hundred pounds. That she had been a constant 
sufferer all that time, and had been frequently under treat- 
ment for womb disease. She was at this time a dyspeptic 
in so far that she thought that an ordinary diet disagreed 
with her ; but she attributed her loss of flesh more to the pain 
that she suffered than to any lack of food. She said she was 
constipated all the time, but, upon questioning her closely, I 
found that it was the dread of pain, which occurred every time 
the bowels moved, that prevented her from going regularly 
to stool. She hesitated about submitting to an examination, 
but said that her physician had advised her to do so, and she 
had at last consented. Externally there was nothing around 
the anus to indicate any trouble. She did not give a his- 
tory of any discharge from the rectum at all. I attempted to 
open the anus for inspection, when she began to cry, saying 
that it would kill her to have an examination. I of course 
assured her that it would not, and proceeded. Even with 
the sphincter pushed down by a straining effort, I still could 
not detect any fissure or ulcer. Anointing my finger and 
gradually pressing toward the perinseum, I at last had it in- 
troduced through the spasmodic, irritable muscle. When I 
turned my finger dorsally I felt a small, depressed, and very 
sensitive spot, and the touch caused her the most excruciat- 
ing pain. Above this I could feel no disease. After the ex- 
amination I assured her that she could be easily cured. She 
could scarcely believe this, but said that she would consult 
her physician and would let me know. In a few days Dr. 
Foree came to my office and remarked that the strange part 
of the case was that he had treated that woman for several 
years, and had her then under treatment for womb disease, 



314 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and that she had never referred in any way to this rectal com- 
plication until the morning that he advised her to come to 
me, and that then it was purely an accident that he discov- 
ered its existence. In his effort to introduce a vaginal specu- 
lum he had pressed more than usual upon the septum, when 
she cried out with pain, and he had asked her what caused 
it. She replied that she had had trouble there for a number 
of years. When he asked her why she had never mentioned 
it to him, she replied that, in order for him to find out what 
the trouble was, he would have had to make an examination, 
and that her modesty forbade it. The doctor remarked that 
it was so ridiculous, after having treated her a number of 
times for uterine trouble, that he would scarcely have be- 
lieved it if it had not occurred in his own practice. It was 
under this distinguished physician's observation that a pa- 
tient had been treated for uterine trouble by him for a long 
time, when she incidentally mentioned one day that she had 
a bad case of piles, and when he asked her why she had 
never told him of it, she replied that she did not think that 
he was a pile doctor. Of course the existence of the haemor- 
rhoidal tumors played a great part in keeping up the dis- 
tress in the uterus. The operation of divulsing the sphinc- 
ter was practiced upon the woman suffering from the irri- 
table ulcer and she was at once relieved of the terrific pain 
with which she had suffered for five years. 

It is singular that an ulcer could exist for so long a time 
as it did in this case, and not extend to any greater degree 
than it did, and I can only account for the fact by noting 
that it was a small ulcer with a hard base and indurated bor- 
ders, the inflammatory deposit being sufficient to prevent any 
extension of the ulceration. 

Case XIII. — A man, aged about thirty, by occupation a 
street-car driver, came to me complaining of pain at the act 
of defecation, but more especially for the reason that he had 
had an excessive diarrhoea for twelve months that could not 
be controlled by medicine, and that it so interfered with his 
occupation that he was forced to give up his job. My opin- 



ANATOMY OF THE RECTUM AND THE REFLEXES. 315 

ion was, while he was stating his case, that his diarrhoea had 
caused some abrasion or perhaps ulceration near the sphinc- 
ter, and was therefore a secondary consideration. I exam- 
ined his rectum, and found dorsally situated, just between 
the two sphincter muscles, scarcely embracing the fibers of 
either, a well-defined but small ulcer. It did not appear to be 
very sensitive to the touch, nor did it present any of the 
characteristic symptoms of an irritable ulcer. I still was at 
a loss to know whether the diarrhoea caused the ulcer or the 
ulcer caused the diarrhoea. I told him that if he could sub- 
mit to a little pain I thought I could cure him. I took a 
bivalve speculum and introduced it into the rectum, when 
the ulcer was brought plainly to view. Then with a scoop I 
scraped the ulcer very thoroughly, and he gave no evidence 
of very great pain from what I did. He came back to me on 
the third or fourth day saying that he had more pain than 
when he first consulted me, but a less number of actions 
within the twenty- four hours. I again brought the ulcer 
into view, and made an application to it of pure carbolic 
acid, after which I deposited vaseline on the surface I pre- 
scribed the following as an injection : 

^ Hydrate chloral gr. xx ; 

Powdered opium gr. j ; 

Aquse dest 5 j. 

To be thrown into the rectum each night at bed-time. 

After one week's treatment with this preparation his diar- 
rhoea ceased, and I substituted an injection of oil and bis- 
muth, to be used each day until all sensitiveness had disap- 
peared. He was permanently relieved. 

Of course it can be seen that this man's diarrhoea was 
caused by the existence of an ulcer in the rectum, and yet 
this ulcer was not an irritable one, but it was located just at 
the spot where it could excite nerve irritation, to produce a 
peristaltic action of the bowel which kept up a teasing diar- 
rhoea. 

I have had occasion very often to speak of the part that 
the sphincter muscle plays in rectal disease, and by its spas- 



316 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

modic action to be responsible for both diarrhoea and consti- 
pation, but, as I have fully alluded to this subject in the chap- 
ter on the Hysterical Rectum, I can only incidentally refer to 
it here. 

Six or seven years ago I reported to the Kentucky State 
Medical Society a case of epilepsy relieved by an operation 
for internal haemorrhoids. Since that time I have recorded 
four other cases of epilepsy cured by an operation upon the 
rectum — one a case of simple ulceration, the three others 
where the operation was done for fissura ani. 

Case XIV. — A physician in an adjoining State brought a 
lady patient to me whom he said was an epileptic, and that 
she also suffered with a severe pain in the rectum. He had 
known for a number of years that she had these " swooning" 
spells, and, after seeing her in one, had pronounced it epi- 
lepsy. The woman was about thirty-five years of age and in 
good flesh. Her appetite was good and the secretions active. 
Her family history revealed no epilepsy. Her physician 
had ascertained the fact that her attacks had some rela- 
tion to the condition of the bowels ; that when her bowels 
acted, and the actions were soft, they did not appear to in- 
fluence the attacks ; but whenever she was constipated and 
passed a hard action, she was certain to have an epileptic 
spasm. The patient stated to us that she had more or less 
pain in the rectum all the time, but that it was aggravated in 
the manner described by the physician. I examined her rec- 
tum in the presence of her doctor, and found that the sphinc- 
ter muscle was hypertrophied and very irritable. No distinct 
ulceration existed. I suggested that she be chloroformed and 
the sphincter forcibly divulsed. This was done, and the 
woman kept under observation at the infirmary for several 
weeks. During this time she did not have any epileptic con- 
vulsions, nor did they ever appear again. 

Another case somewhat similar to this was the following : 

Case XV.— A lady, aged about twenty-eight, was referred 
to me by one of our local physicians. The doctor stated in 
his note that she suffered from constipation, and that she had 



ANATOMY OF THE RECTUM AND THE REFLEXES. 317 

on an average one or two swooning spells a week, but that 
lie ascertained the fact that they invariably occurred in the 
water-closet during the act of defecation. Frequently on the 
street she would experience a feeling as if she would lose con- 
sciousness, but never had except under the circumstances 
mentioned. An examination per rectum caused her some 
pain, and I desisted from a further exploration because she 
said that she believed she would faint. I advised her phy- 
sician to try the divulsion plan upon her, which he had me 
do several days later. This patient was watched for a num- 
ber of months and had no recurrence of her epilepsy. 

I have recited this number of cases and variety of patients 
with the treatment in order to show what powerful reflexes 
can occur from the rectum. I have also tried to be explicit, 
in narrating the symptoms and stating the disease, to demon- 
strate more fully my views upon the subject of the so-called 
" hysterical or nervous rectum" vs. a diseased condition in 
the rectum. I believe that all the symptoms which follow in 
the train of either one of the affections are due to a patho- 
logical change. It is a subject that has not been brought as 
prominently before the profession as it should have been and 
that its importance demands. I have aimed in this chapter 
to give a recitation of facts, substantiated by a report of cases 
occurring In my own practice, and tried at the same time to 
explain the condition from an anatomical standpoint. 



CHAPTER XIV. 

ULCERATION OF THE RECTUM. 

Simple ulceration of the rectum, located above the sphinc- 
ter muscles, is a very uncommon disease. I have already 
taken occasion to state that, in my opinion, some of the 
causes of stricture of the rectum, as given by the writers on 
this subject, are not only infrequent but really are no causes 
at all. Prominent among these I mention dysentery. If 
we are to accept the dictum that dysentery is a common 
cause for stricture or even ulceration in the rectum, how can 
we accept the declaration of Allingham, Ball, and others, 
that a benign ulceration of the rectum is a very uncommon 
disease ? As I have already stated, dysentery is a very com- 
mon affection in nearly all climates, especially the warmer 
ones ; and I should imagine that if it produced stricture at 
all, we would be frequently called upon to treat a.t least the 
ulceration that was the precursor of it. My observation has 
been that the sequelae of dysentery are not to be found in the 
rectum, but more especially in the colon. It is a notable fact 
that an ulceration, very extensive in character, may exist in 
the rectum located above the sphincter muscles and cause 
very little disturbance, or at least the disturbance is out of 
all proportion in its insignificance to the extent of the ulcer- 
ation. It is only where the external sphincter muscle is im- 
plicated in the disease that we have the great distress fol- 
lowing. 

Case. — Miss M. L., aged twenty-one, was sent to my office 
by her physician for some rectal disturbance. She gave a his- 
tory of diarrhoea, or, more properly speaking, a dysenteric 
discharge. Her general health at this time was very good, 



ULCERATION OF THE RECTUM. 319 

and she complained most of the general sense of uneasiness 
in the rectum and back, abdomen, etc., and did not speak of 
any particular pain. Placing her on the table and introduc- 
ing my finger, I detected an ulcerated surface that embraced 
the full circumference of the bowel and extended upward 
nearly as far as my finger could reach. I could detect no 
effort of constriction of the gut. The entire mucous mem- 
brane was denuded, but the sphincter muscle was not in- 
fringed upon. Consequently I was surprised to see this girl 
in as- good physical condition as she was, and to hear her 
complain so little of distress, pain, etc. I could not trace a 
history of syphilis, and I was satisfied that it was not 
malignant, consequently I was at a loss to understand the 
cause for such trouble. The patient had never had dysen- 
tery, nor was she of a scrofulous or tuberculous diathesis. 
Consequently, had I believed in such causes of the trouble, I 
could not have traced them here. I put this girl under the 
following directions and treatment : She was ordered to take 
a small dose of the sulphate of magnesia, often repeated, until 
a free purgation occurred, and then to wash out the rectum 
freely with very hot water. When I called, these directions 
had been complied with. I placed her in Sims's position upon 
a hard bed, and introduced a speculum, and, opening it, I 
could see the bowel to nearly the full extent of the ulcera- 
tion. I then applied freely a solution of the nitrate of 
silver, forty grains to the ounce, to the entire denuded sur- 
face. It is remarkable of what strength caustics, etc., can 
be used in the rectum. I have frequently used pure car- 
bolic acid to these ulcerations, and the patient complained 
of no pain at all unless it was allowed to trickle down over 
the surface of the anus. The true skin surrounding this out- 
let is very susceptible to the action of such drugs, but the 
mucous membrane of the rectum will bear it to most any de- 
gree. This girl was put upon a milk diet, which included 
soups and some other liquids, and ordered to remain in bed. 
Upon my second visit and examination, I found the surface 
of the ulceration very much reddened — consequently, to my 



320 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

mind, much healthier. I then soaked into the ulceration a 
mixture of sweet oil and iodoform, one to ten parts, and 
withdrew the speculum. After this I had her syringed daily 
with the preparation that follows : 

^ Olive oil Oj; 

Aristol 3 iij ; 

Hydrate chloral 3 j. 

M. Inject one ounce, after shaking the mixture well, 
twice a day. 

By a long course of treatment this ulceration gradually 
healed, and the patient was restored to health. 

I am satisfied, in dealing with cases of this kind, that a 
point of the greatest moment is to confine them to bed, for 
unless this is done it is very nearly impossible to cure them. 
A second point is to give the bowel a rest in not allowing any 
hard faeces to pass over it. I wish to observe here that the 
purgation of one day will not generally suffice to empty the 
intestinal tract, for it will be observed that three or four 
times at least, after you have begun treatment, a considerable 
amount of faeces will pass in response to the aperients given. 
It is not my custom to confine the bowel long in treating this 
character of ulceration, but I cause an evacuation at least 
every second or third day by an enema or by an aperient. 

Varieties. — It is very natural to suppose that the rectum 
could be ulcerated because of its peculiar office. I have given 
reasons for supposing that it is not the receptacle for the 
feces except temporarily ; but the physiology of defecation 
proves that it is the receptacle at least for a part of the dried 
portion of the faecal mass. This condition, of course, excites 
a friction, or, we might say, a continual irritation of the mu- 
cous membrane of the bowel, which has a very large blood- 
supply. Yerneuil has drawn attention to the fact that the 
pressure that the veins of the rectum of necessity must be 
subjected to during the act of defecation is a fertile cause 
of haemorrhoids and congestion. Whereas I do not hold to 
his view — that the haemorrhoidal veins penetrate small open- 
ings in the muscular coat and are unprotected by any ten- 



ULCERATION OF THE RECTUM. 321 

dinous ring— I do believe that because these veins are desti- 
tute of valves is a sufficient reason for the poor circulation 
in returning the blood. Therefore if the fsecal mass be re- 
tained in the rectum, the pressure tends to produce stasis 
in the small terminal branches. The same thing can be said 
concerning any pressure that is exerted upon them, as, for 
instance, a displaced womb or tumors, or perhaps tight lac- 
ing, etc. In persons suffering from a diseased condition of 
the liver, as is often witnessed in the drinking man, this pre- 
disposition to a congestion of the veins of the rectum is made 
manifest through the portal circulation. If observed in time, 
a congested condition of the vessels can be relieved by proper 
advice or treatment. If it is allowed to go on, the pathologi- 
cal changes take place in the walls of the blood-vessels, espe- 
cially the veins which constitute or go to make up the phe- 
nomena of inflammation ; and yet I am satisfied that it is not 
at all necessary or to be concluded that proctitis results in 
consequence, for the disease seems to be confined to the blood- 
vessels, and very seldom extends to the subjacent tissues or 
the mucous membrane. The condition in the rectum, uuder 
these circumstances, is very similar to that constituting varices 
generally, and which is observed especially in the veins of the 
leg, supervening upon pregnancy. Now, we very well know 
that it is our custom to say to the pregnant woman who is 
disturbed by the small hemorrhoid which everts from the 
anus with the least exertion, that she need not be disturbed 
by this, because, when the delivery of the child takes place, 
the hsemorrhoid is likely to disappear. This is a case of cause 
and effect. So it is with varicose veins anywhere. I have 
often thought that if the importance of keeping the intestinal 
tract clear of any accumulation could be taught to common 
people at least, the number of cases of haemorrhoids would be 
greatly reduced. Preventive treatment is certainly better 
than operative, and yet very few people are instructed how 
to prevent haemorrhoids and other rectal affections, under 
which this class of ulceration which we are now considering 
falls. 

21 

/ 



322 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

It is singular to observe how quickly inflammation of the 
mucous membrane of the rectum is followed by ulceration, 
and how infrequent it is to observe ulceration as the result of 
the congestion or varicose condition of the vessels in the rec- 
tum. This can only be accounted for by the fact that the 
vein walls are thickened by the process of inflammation and 
become less yielding, instead of the reverse. It can not be 
denied that some special diatheses are attended with ulcera- 
tions at different localities of the body. Now, under this 
head we must of necessity classify tubercular, scrofulous (?), 
and those due to syphilis. 

We have all witnessed the deposit of tubercle in the glands 
surrounding the neck of the ill-nourished child, and especially 
those of the negro race, and the consequent ulceration of the 
same. Now, it is a conceded fact, since tubercle is better un- 
derstood than formerly, that this disintegration and degen- 
eration of tissue can take place in and around the rectum, as 
in any other portion of the body. I have taken the position 
in a former chapter that I did not believe that tubercle was 
the cause, of stricture of the rectum, as supposed by some, 
from the fact that this peculiar deposit so quickly breaks 
down that, before it has filled the rectum to such a degree as 
to constitute a stricture, it will have softened and given way. 
I know that different authors have recorded cases of supposed 
tubercular stricture of the rectum, and yet I am inclined to 
think that a close investigation would perhaps have changed 
the diagnosis. Whereas I do not believe in tubercular strict- 
ure, I regard tubercular ulceration of the rectum as one of 
the common causes of this condition, and, unfortunately, this 
character of ulceration is the most difficult of all in which to 
set up the reparative process. Indeed, it will be found that, 
unless the general constitutional condition can be improved, 
the healing process can not be established in the ulceration, 
and therefore sometimes we are forced to resort to meas- 
ures only looking to the relief from pain, etc., and direct that 
the patient seek such climate, indulge in such outdoor exer- 
cise, live upon good nutritious food, attend carefully to the 



ULCERATION OF THE RECTUM. 323 

secretions of the body, including bathing, massage, a pleasant 
occupation, a freedom from mental distress, tonics, stimu- 
lants, etc., as will tend to accomplish this purpose. Among 
the very first symptoms or conditions with which we meet in 
tubercular ulceration of the anus or the rectum is the actual 
breaking down and softening of the structures. This has 
been designated by some as a cold abscess. 

Case. — A young lady came to me by the instruction of 
her family physician, who sent a note by her to explain her 
condition. In this communication he told me that this girl 
had lost two sisters and her mother with consumption, and 
that she had a deposit of tubercle in one lung. She told me 
that she frequently had night-sweats, had lost quite a good 
deal of flesh, had very little appetite, and was despond- 
ent. When asked to give symptoms for which she consulted 
me, she said that she felt an uneasiness in the neighborhood 
surrounding the rectum ; that there was no acute pain, but 
that when she sat down it disturbed her, and that she was 
unable to take much exercise. I put her on the table and in- 
spected the parts. There was a puffy condition to the left 
side, extending as far backward as the coccyx. Fluid could 
be easily detected under the skin, and yet when an even 
pressure was made with my hand it seemed to relieve her 
instead of aggravating her symptoms. The mucous mem- 
brane of the rectum was not ulcerated, but the fluid was 
evidently just under it, for it was very much thinned. My 
first impression was, which I carried out, to give free vent 
to the contents of this cavity. I had her go to an infirmary, 
and upon the next day I freely incised from the outside, 
thus hoping to save the mucous membrane and prevent an 
internal opening. The contents evacuated were of a bloody, 
watery appearance, filled with the debris of tubercular tis- 
sue. Although this cavity was carefully washed out daily 
with an antiseptic solution, I was satisfied that it would not 
heal, but, on the contrary, the degeneration of tissue began to 
extend. I was placed here between two fires. If I operated 
on this girl I would be compelled to cut away a good deal of 



324 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

tissue, knowing at the same time it would be difficult to get 
the wound to heal ; and, on the other side, if I did not oper- 
ate, the destruction would rapidly progress. I hesitated, 
too, about putting her in bed, believing that confinement 
would make her general condition worse. Again, it must 
be observed that the succussion in the phthisical patient 
caused by coughing is very detrimental to the healing pro- 
cess. I determined, however, to accept that which I consid- 
ered the least of two evils, and to operate. This I did on the 
fourth or fifth day after seeing her. She took ether kindly, 
and I laid open the cavity to its full extent, running parallel 
with the bowel, and, on introducing my finger into the rec- 
tum could detect that the mucous membrane had given way 
and a large internal opening presented. I ran my grooved 
director into the rectum through this opening and divided the 
tissues. There was much overlapping skin, which I lifted up 
and carefully trimmed off with my scissors to the furthest 
edges of the wound. Even then some loculi were observed, 
which I broke up with my finger and trimmed the skin from 
over that section. In other words, I did not leave any pocket 
whatever ; I left the bottom of the wound fully and wholly 
uncovered. When I was through I had made quite a large 
wound. I was afraid to dust it with iodoform, so I contented 
myself with laying iodoform gauze over it. Surgeon's cotton 
was then placed in position and a T-bandage applied. She 
rallied nicely from the ether, and neither then nor at any 
other time complained of any pain from the operation. On 
the second day she expressed a desire to get up and walk 
around the room, which I permitted. Indeed, I advised her 
to remain up each day as long as she desired. I looked after 
the wound carefully and put her upon a constructive treat- 
ment, and, strange to say, though it took a longer time than 
usual, this wound entirely healed, and after it did so the girl's 
general health very much improved. 

There is another form of ulceration in the tubercular sub- 
ject that attacks the mucous membrane and tissues within 
the rectum, showing no evidences on the outside, and I have 



ULCERATION OF THE RECTUM. 325 

seen a number of cases where much confusion arose as to how 
to classify the ulcer, from the fact that otherwise the patient 
appeared to be free from tuberculosis. The following case 
will illustrate this condition. 

Case. — A few months ago one of the business men of this 
city, aged about forty, came to consult me about his rectum. 
He said that he was discharging some mucus each day, ac- 
companied by a good deal of tenesmus, but complained of no 
particular pain. I examined his rectum and found one dis- 
tinct ulcer, beginning just above the sphincter muscle and 
extending upward. It was not oval, but more of a conical 
shape, the base of the cone being below. It had the peculiar 
characteristics of a tubercular ulcer, although a broken sur- 
face ; there was no pus. The base was a glairy, palish red. 
No particular pain was noticed when I touched it. There 
were no well-defined edges, and yet the ulcer had some depth. 
He had given me his general history, but upon getting off the 
table he informed me that for a couple of years he had been 
traveling in order to keep him in a climate that would cure 
a lung trouble said by his physician to exist. During this 
time he had been much in France and Egypt, latterly in 
North Carolina, and had been pronounced by his physician 
as cured of his lung trouble. He had no longer any cough, 
expectoration, night-sweats, or indeed any symptom which 
pointed to phthisis. He had a good appetite, had gained 
flesh, and expressed himself that, as far as his lung disease 
was concerned, he was a well man, and to all appearances he 
was so. I said to him that I believed he had a tubercular 
ulcer in his bowel, for which I prescribed by first making 
a local application to the ulceration and afterward advising 
an injection to be used by himself. In a few weeks he told 
me that he was compelled to go East on some business, and 
asked me to refer him to some good authority that he might 
be re-examined for his lung disease. I did so, and while 
gone he consulted a very distinguished diagnostician. I 
should say here that, during one of my talks with him, I 
advised him to leave this country, at least for the winter, 



326 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and I thought a trip across the ocean and a stay in the south 
of France would benefit him. The authority to whom I re- 
ferred him told him that he still had trouble in one lung, 
and quite agreed with me that he should go abroad. The 
patient made known to this consultant that he had some rec- 
tal trouble, and I had so mentioned in my note to the doctor, 
and having understood the patient to say that he would not 
return to Louisville for a year or more, he advised him to 
have a surgeon in Philadelphia examine his rectum. He did 
so, and the surgeon advised that this ulcer should be scraped 
out. He was put under ether, and by the use of a scoop, 
together with a thermo- cautery, the operation was done. He 
was confined to the hospital for several weeks and then re- 
turned home. I took exception to the method of treatment 
for the rectal ulceration, and so wrote the physician who had 
examined his lungs. I recognize that under the accepted 
pathology of tuberculosis it appears reasonable to so treat 
such ulcers, but my observation has been that under such 
treatment they are oftentimes made worse, certainly not bet- 
tered. My plan is never to treat a tubercular ulcer of the 
bowel which looked like this in any such manner, but, on 
the contrary, to look after the general health of the patient, 
and by a gentle stimulating treatment of the ulcer, with a 
strict attention to cleanliness, the ulceration will usually take 
care of itself. If the general health improves, the ulcer will 
improve under this kind of treatment. If the tuberculous 
condition of the lung extends, the ulceration of the rectum 
will also extend. Hence the advice to the patient to go to 
the south of France for his general health, and to follow out 
the simple directions for the ulceration, which would have 
given him very little inconvenience. He took my advice and 
went abroad. 

In referring to the first case reported here, it might be said 
that I did an operation with the knife upon a tuberculous 
condition of the rectum and anus, but it will be quickly seen 
how very different the two conditions were. In the first case 
there was a cavity filled with an ugly fluid and simply cov- 



ULCERATION OF THE RECTUM. 327 

ered by a layer of skin in a necrosed condition and endan- 
gering the mucous membrane of the bowel. The gist of the 
operation was to cut away all this offending skin, discharge 
the contents of the cavity, allow free drainage, which left at 
the bottom an indolent, tubercular ulceration, and the treat- 
ment of that ulceration, or the w r ound, if you please, was by 
the same manner that I suggested for the ulceration inside 
the man's bowel, reported in the second case — viz., attention 
to the general health of the man and a gentle stimulating 
treatment of the ulcer. Molliere propounds the question 
whether, if a tubercular ulcer be completely extirpated or 
destroyed before general symptoms of tuberculosis had 
shown themselves, it might not be possible to prevent the 
general manifestations of the disease. Now, this is a very 
nice point to raise, but I am inclined to believe that the ex- 
tirpation or the destroying of the ulcer would not prevent the 
general manifestation of the disease ; but in this last case, 
which I have just reported, it will be observed that tubercu- 
lar disease had existed in this man's lungs for several years. 
Even admitting that it was cured at the time I saw him, at 
which time a tubercular ulcer existed in the rectum, the 
case does not fall under the class described by Molliere. 
So I must say that I believe that for such ulceration as I 
have described of a tubercular origin, operations looking 
to its extirpation or its destruction should not be prac- 
ticed. 

Scrofula. — Scrofula is such a vague term, and conveys such 
little meaning, that I am not inclined to put it down as a 
special class of ulceration. For very many years the scrofu- 
lous taint has been believed by some of the very best authori- 
ties to be a synonym with the syphilitic diathesis. I am 
more inclined to class this form of trouble, especially of 
ulceration, under the head of those just named — viz., tuber- 
cular. The distinction is so fine that, even to admit the pre- 
mise of authors who make this classification, it aids us very 
little in the treatment, because a so-called scrofulous ulcera- 
tion would be treated exactly similar to a tubercular ulcera- 



328 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

tion. If we find such ulceration in the young, I would be 
inclined to believe with Yan Buren that it was caused by 
the grafting of the syphilitic poison upon the scrofulous 
diathesis. 

Kelsey says that this form of ulceration is best treated by 
destructive cauterization and raclage. I can not believe that 
this is a good plan, but am more inclined to believe that by 
watching the local trouble for any complication that might 
arise, and placing the patient npon the same general charac- 
ter of treatment that we do the tuberculous, we would run 
just as good a chance of a final cure. In the chapter on 
stricture of the rectum I have maintained that syphilis is 
the most common cause for it, hence I believe that it is also 
the most common cause for ulceration of the rectum. I 
shall refer here more especially to the secondary manifesta- 
tion of the disease, or tertiary syphilis. I shall not take 
the time to deal again with the manner in which I believe 
this ulceration occurs, but make it suffice to say that it is 
of gummatous origin. I have also stated the way in which 
this ulceration can be diagnosticated from other forms of 
ulceration ; therefore it devolves, in this chapter, only to 
speak of the treatment after you have made out the diag- 
nosis. I firmly believe that where syphilitic ulceration of 
the rectum has produced sufficient change to amount to a 
stricture of the gut, this stricture, being of a fibrous nature, 
is incurable. I do not believe that by any antisyphilitic 
medication this fibrous structure can be reabsorbed. So firm 
am I in this belief that whenever I see a person suffering 
with a rectum filled with gummatous deposit, with a coinci- 
dent stricture or strictures, I pronounce it as incurable as 
cancer. But if we see a patient sufficiently early to detect 
the syphilitic ulceration in the bowel, then the prognosis is 
much more favorable. The treatment of this form of ulcera- 
tion is very much like that of the tubercular ulcer, for the 
ulceration is generally indolent in its character. But we must 
not be impressed with the idea that its characteristics are the 
same as those of either simple or tubercular ulceration. The 



ULCERATION OF THE RECTUM. 329 

pathology is entirely different. Simple ulceration arises from 
trauma, a lesion being produced in some manner. Tubercu- 
lar ulceration is a breaking down of tissue, and is due to 
the tubercular bacillus. Syphilitic ulceration is a second- 
ary condition, is a morbid deposit which takes place in the 
tissues underneath the mucous membrane, and, by its grad- 
ual growth, is subjected to friction by the passage of faeces, 
etc., and then has its surface ulcerated. But this ulcera- 
tion does not cause any particular destruction to the mor- 
bid deposit, for the building process of the same still goes 
on. In simple ulceration we are to rely upon simple local 
measures ; in tubercular ulceration we place the greatest 
stress upon the attention to the general health ; in syphilitic 
ulceration we are to fight the special diathesis by antisyphi- 
litic medication, and generally it will be found a very hard 
fight indeed. Therefore the treatment must be as the treat- 
ment for secondary and tertiary syphilis usually is. The two 
agents to be relied on are mercury, in some one of its varied 
forms, and the iodide of potassium. These patients are much 
benefited by a sojourn at Hot Springs, Arkansas. While there, 
they are enabled to take a much larger amount of these agents 
than when at home. I believe that an explanation for this 
can be found in the sweating process that they are made to 
undergo in taking the hot baths. The ulceration in the rec- 
tum should be looked after in this manner : By using a good 
speculum, the entire surface should be brushed a number of 
times with a solution of bichloride of mercury (1 to 3,000). If 
at any one point the ulcer is especially indolent, I frequently 
apply pure carbolic acid. As a cleansing agent, the peroxide 
of hydrogen is the best. As a stimulating injection, nitrate 
of silver, campho-phenique, carbolic acid, and fluid hydrastis 
in solution, are admirable agents. The bowel should be kept 
in a soluble condition and the secretions looked after. It is 
often a question with physicians what amount of iodide of 
potassium should be given a syphilitic patient. I think each 
case should be considered an individual one and allowed to 
tell its own story. This is the remedy, above all remedies, 



330 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

that is given for its effect. I am in the habit of prescribing, 
as a beginning, ten drops of the saturated solution in a half- 
glass of water three times a day, and increasing from two to 
five drops each day until, if the case seems to demand it, I 
reach as much as fifty drops at a dose, or one hundred and 
fifty grains per day, to be taken indefinitely and its effects 
carefully watched. It should always be seen that it is fully 
diluted with water. Sometimes you will see a patient who 
has an idiosyncrasy to the drug, and its effect may be mani- 
fested by the taking of a few grains. Of course, in these 
cases, the physician is to determine what is best to be 
done. I am satisfied that I have seen quite a number of ul- 
cerations of the rectum get well under this kind of treat- 
ment. It should not be forgotten that, along with the mer- 
curial and iodide treatment, these patients need a good 
tonic course as well. Some one of the good tonics should 
be given. One of the best is the elixir of iron, quinine, and 
strychnine. 

For the anaemia which frequently follows antisyphilitic 
treatment or the disease itself, or for the same condition 
produced by struma, tuberculosis, etc., a most admirable 
preparation will be found in the Elixir of the Three Chlo- 
rides with Calisaya prepared by Renz & Henry, of this city. 
Each fluidrachm contains an eighth of a grain of protochlo- 
ride of iron, T fa grain of bichloride of mercury, and -^is 
grain of chloride of arsenic. I have derived much benefit 
from treating this class of patients with this preparation. 
Indeed, it is wonderful to see the rapid improvement in all 
enfeebled natures, especially the syphilitic, after taking the 
three chlorides. 

Under this classification of ulcers of the rectum, but more 
especially of the anus, I wish to speak of chancroids. They 
are said by Pean and Malassez to have constituted nearly one 
half of all the ulcerations in this region examined at the 
Lourcine in 1868. I can not understand how it is that, if 
this statement is correct, we in America have seen so few 
cases. 



ULCERATION OF THE RECTUM. 331 

I am sure that I never saw a stricture of the rectum pro- 
duced by chancroidal pus, and I can not remember to have 
ever seen an ulcer on the mucous membrane of the rectum 
caused in this manner. We do tolerably often see condylom- 
ata around the anus, and such a condition is very ugly, and 
may be so extensive as to often lead the physician to suspect 
that he is dealing with a more serious condition than exists. 
But we must remember that all condylomata are not syphi- 
litic. This condition is recognized by the elevation above 
the cuticle, in a well-defined grouping, of what appear to be 
small, nodular tumors, with an ulcerated surface, discharg- 
ing pus. But of all forms of ulceration around the anus, or 
in the rectum, this is the most amenable to treatment. Abso- 
lute cleanliness of the parts should be brought about by hot 
water and Castile soap, then drying off and applying the fol- 
lowing : 

5 Bismuth, subnitratis 3 ss. ; 

Hydrarg. chlor. mit 3 iij. 

M. Sig. : Dust on the parts. 

Under this treatment this condylomatous mass frequently 
disappears as if by magic. If the ulcerations appear to be at 
all indolent, I have found it best to irrigate them with a solu- 
tion of bichloride of mercury (1 to 3,f)00). 

Dysentery.— I have taken the position, in the chapter on 
stricture, that I did not believe that dysentery was a com- 
mon cause of stricture, as is stated by some. In giving my 
reasons I stated that an ideal case for a pension would be 
where a soldier should show a stricture of the rectum re- 
sulting from dysentery contracted during a war, and inci- 
dentally remarked that the Pension Office was singularly 
quiet on that point. I have just noticed that in the Medical 
History of the War of the Rebellion Dr. Woodward remarks 
that stricture resulting from dysenteric ulceration seems to 
have been much rarer than might have been supposed, and 
that no case has been reported at the Surgeon -General's Office, 
either during the war or since ; that the Army Medical Mu- 
seum does not contain a single specimen ; nor has he found 



332 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

in the American medical journals any case substantiated by 
post-mortem examination in which this condition is reported 
to have followed a flux contracted during the civil war. It 
is only since taking up this chapter that I have seen this state- 
ment from Dr. Woodward, and I am glad to see that it sub- 
stantiates so fully the opinion that I have expressed. Dysen- 
teric ulceration of the rectum, however, is sometimes seen, 
although not as often as one would suppose. We more fre- 
quently have colitis existing as the result of dysentery than 
proctitis, and I believe the sigmoid flexure is affected of tener 
in this manner than the rectum. These ulcers appear isolated 
and are very seldom grouped. I believe that their origin oc- 
curs by the peeling off of the epithelium, and the friction 
to which they are afterward subjected by the faeces or strain- 
ing, or both, tends also to implicate the mucous membrane. 
If the dysenteric patient could be watched and have his rec- 
tum irrigated after his attack, I dare say that the number of 
cases of dysenteric ulceration, although already few, would 
be diminished. 

Treatment. — If it is supposed that the ulceration is the re- 
sult of dysentery, the same treatment would obtain as pre- 
scribed for simple ulceration from other causes — viz., an abso- 
lute rest given the bowel by first causing a free evacuation in 
order to clear out the intestinal tract, rest in bed, and sooth- 
ing applications locally applied. In such a case I would use 
frequent injections of very hot water, not only for the pur- 
pose of cleansing the mucous membrane, but for its stimu- 
lating property as well. If an ulcer is defined and evinces 
an indolent disposition, one of the best local applications 
is pure carbolic acid. In making this application it is well 
to guard the surrounding mucous membrane by seeing that 
the cotton on the probe is not over-supplied with acid, and 
also to use an application of vaseline around the contigu- 
ous parts after the application. As a subsequent local appli- 
cation, I am in the habit of using iodoform for ulcers of the 
rectum by distending the sphincter muscles with a specu- 
lum and blowing the powder by means of an insufflator 



ULCERATION OF THE RECTUM. 333 

upon the diseased membrane. As an injection, a prepara- 
tion of iodoform or aristol, one drachm to eight ounces of 
olive oil, one ounce to be injected each night at bed- time 
by the patient. By absolute rest, and under this treatment, 
such ulcers would be very likely to heal. I very seldom in- 
ject opium for ulceration of the bowel. It is very true that, 
of all agents, it is the quickest to quiet pain and distress, but 
it establishes a habit which is hard to overcome. In ulcera- 
tions of the rectum which have existed for any length of time 
and show a well-defined, hardened base Avith indurated bor- 
ders, it is a good plan to scarify them, and especially to see 
that the kirife goes through the edges of the ulcers. This 
should be done before any special treatment is begun. 

Ulceration from Foreign Bodies. — Of course it is an admitted 
fact that traumatism, the result of the introduction of for- 
eign bodies into the rectum, may be followed by ulceration, 
and yet this should be classed under the head of simple 
ulceration and treated as such. It is remarkable the number 
of foreign bodies and the character of some that are some- 
times found in the rectum. In many cases the patient will 
absolutely deny that any effort has been made to introduce 
the foreign body into the rectum, and yet, upon investigation, 
such may be found, and, unless removed, might result fatally ; 
to the contrary, the surgeon might be led into error by the 
statement of patients as to the swallowing of foreign bodies 
or substances. 

Case. — A short time ago a young gentleman came to my 
office in very great distress of mind. In giving me a history 
of his disturbed condition, he said that he had the day before 
swallowed his upper set of teeth, including the plate. I 
asked him to tell me how this was done, and he replied that 
while eating raw oysters at a restaurant it must have oc- 
curred, from the fact that, as he was leaving the place, he 
detected that the plate containing his teeth was not in his 
mouth. Upon further questioning, I ascertained the fact that 
before going to the restaurant he had placed postage stamps 
upon a number of letters, and that to moisten the stamps he 



334 DISAESES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

would insert a number that were attached into his mouth 
against this upper plate. I suggested to him that possibly 
the suction and the gum arabic upon the stamps had been 
the means of drawing the plate from his mouth without 
his knowledge. In questioning him for symptoms of any 
foreign body in the intestinal tract or stomach, he placed 
his hand over the region of the sigmoid flexure and said he 
felt pain there. It was a question in my mind whether so 
large a body could pass the ilio-csecal valve. It was my 
own opinion that if he had swallowed the body it was still 
in the stomach, and possibly gastrotomy would have to be 
done. I asked him, however, to dismiss the subject from his 
mind by trying to persuade himself that he had not swal- 
lowed the plate, and come to see me the next day. He failed 
to report, and, as there were no further developments, I sup- 
pose that it was a fact that the source of his trouble was in 
his mind and not in his stomach. 

As I have intimated, foreign bodies are often introduced 
into the rectum with malice or by intention, and, if of such a 
size as would admit of it, will find their way upward into the 
colon. Such bodies may include pieces of wood, lead or slate 
pencils, stones, pieces of coin, sticks, pieces of bottles, or 
whole bottles. Velpeau reported the detection of the bottom 
of a long Cologne- water bottle felt beneath the false ribs on 
the right side, where he was enabled to touch the open end 
of the bottle, which was a little over eleven inches long, with 
the finger in the rectum. It was safely extracted, and left 
no bad consequences. The late Valentine Mott reported a 
case where a paving stone had been thrust through the anus 
by malice on the part of a sober companion on his drunken 
friend. In another case, under similar circumstances, a tum- 
bler had been inserted into the rectum. A late writer in one 
of the foreign journals reports the extraction of a large goblet 
which had been thrust into the rectum, and a laparotomy was 
done for its removal. It can be easily understood what the 
danger to life is under such circumstances. M. Gerard made 
a report of thirty-four cases, the fourth of which terminated 



ULCERATION OF THE RECTUM. 335 

fatally. If the patient escapes peritonitis, we may have — ex- 
cited by the presence of the foreign body — inflammation of 
the rectum, gangrene, abscess, fistula, false passages, etc. It 
must be understood that the removal of large foreign bodies, 
especially those of glass, is attended with much danger. 
In one of Velpeau's cases, in trying to remove a beer glass, it 
was broken, and serious laceration of the gut took place. 
The man died in eight days from abscess of the pelvis. As 
far as a diagnosis is concerned, it is generally made plain by 
introducing the finger into the rectum, when the foreign 
body can be found, unless it has been small enough to pass 
up into the colon. 

The method to be practiced for the removal of these for- 
eign bodies must be made to suit the case. Generally it 
will be sufficient to anaesthetize the patient and divulse the 
sphincter muscle freely, and then, by the aid of the fingers 
or forceps, to extract it. It is very well after the sphincters 
are dilated to pour into the rectum an ounce or two of oil, 
which lubricates the parts and aids us materially in the effort. 
If it is found after the divulsion of the sphincters that the 
space is not large enough to admit the removal of the body, 
Esmarch has advised that a free division be made in the me- 
dian line, back to the coccyx. If it is found that the foreign 
body is held higher up, and yet can be detected by the fin- 
ger, the whole hand should be introduced into the rectum in 
order to obtain a good hold upon the foreign body. It has 
already been stated in a former chapter that the size of the 
hand should be considered, and, if necessary, to procure the 
aid of some person having a small hand, and yet it requires 
that the manoeuvre thould be executed slowly and with gen- 
tleness. If all these efforts fail, a laparotomy should be done. 
A number of such cases are reported. 

The ulceration that results from foreign bodies remaining 
in the rectum should, as I have already said, be treated in the 
same manner as simple ulcerations arising from other causes. 



CHAPTER XV. 

NON-MALIGNANT STKICTURE OF THE KECTUM. 

In discussing the subject of non-malignant stricture of the 
rectum, I shall take some positions which are contrary to the 
accepted teachings of the day, but I do so after weighing the 
matter carefully and taking my experience as my teacher. 

iEtiology. — The following classification of the varieties of 
stricture of the rectum is given by Kelsey. It is the usual 
one given by most authors : 

Congenital. — 1. Complete. 2. Partial. 

Acquired. — 1. Spasm, (a) Dysenteric. 2. Pressure from 
without, (b) Tubercular. 3. Non-venereal, (c) Inflamma- 
tory, (d) Traumatic. 4. Venereal, (a) Ulceration (either 
chancroidal, secondary, or tertiary). 5. Cancer, (b) Due to 
unnatural vice, (c) Neoplastic (gummata, anorectal syphi- 
loma). 

The first great division, it will be noticed, is congenital and 
acquired stricture. In writing of or dealing with stricture, 
the idea intended to be conveyed is that of a pathological 
change in tissues, etc., a deviation from the natural, brought 
about by disease. Hence I object to the consideration of con- 
genital malformations of the rectum, or to define them under 
the head of strictures of the gut, for the reason that it is mis- 
leading to do so. It will be more to the point to deal with 
such as atresias. Exception could also be made to the second 
division of this grand classification — viz., the acquired. I am 
aware of the fact that the term is often used in the sense 
herein applied, but to my mind a better classification should 
be employed. It is very easy to understand how one could 
acquire a stricture the result of venery, but it is difficult to 



NON-MALIGNANT STRICTURE OF THE RECTUM. 337 

understand how one could acquire a spasmodic or cancerous 
stricture. But I will adopt, for the sake of discussion, the 
above classification, leaving out the congenital variety, 

1. Spasm. — To this form of stricture I shall prefer two 
objections. First, if it be true that such condition ever 
exists, which I doubt, it should not be classed as stricture at 
all, for the reason that no pathological change is manifest to 
constitute a stricture, and no treatment could be given it per 
se. In other words, it would be a symptom of some lesion 
or trouble outside of the so-called stricture. Second, I be- 
lieve that, from the anatomical construction of the rectum, it 
would be utterly impossible for its lumen to be so constricted 
as to be perceptible as an obstruction by spasmodic contrac- 
tion of its muscular fibers. I might add as a third reason 
that in all my examinations of this part of the gut I have 
never seen a spasmodic contraction that could be called a 
stricture. 

2. Dysenteric. — Although it is frequently stated that dys- 
entery is a common cause of stricture of the rectum, I have 
never seen a case of sufficient worth to convince me of the 
truth of the statement, or indeed that it was a cause at all. I 
have many times seen patients who gave a history of having 
had dysentery, and were treated for a long time for the affec- 
tion, but a close scrutiny of the case revealed the fact that the 
so-called dysentery was caused by an already existing stricture 
and ulceration, the rule here being reversed — that dysentery 
was the result, not the cause. If dysentery really be a cause 
of stricture of the rectum, how very often we would expect 
to meet with it in our practice, considering the great number 
of people who have dysentery, especially in the warmer cli- 
mates ! Again, practitioners of medicine know that ulcera- 
tion proper very seldom exists in the rectum during or after 
attacks of dysentery. The sloughing in these cases occurs 
from the gut above the rectum. I do not deny, but my expe- 
rience has not taught me, nor am I convinced, that ulceration 
of the rectum is caused by repeated dysenteries or diarrhoeas. 

I am sure, at least, that the cases are infrequent. If a long- 
22 



338 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

continued irritation is kept up in the rectum from any cause, 
the result would be, of course, an inflammatory exudate, 
resulting, perhaps, in ulceration and stricture ; but I must 
confess that, in searching for this as a cause, the road to a 
conclusion has not been plain enough for me to put dysentery 
in the list as a cause at all for stricture of the rectum. If 
this disease is a common cause of stricture, as asserted by so 
many, it occurs to me that the trouble would be often found 
in the veterans of war. Indeed, I could not imagine a more 
ideal case for a pension than the existence of stricture of the 
rectum the result of a dysentery contracted while in the 
service, yet the pension records are singularly silent on this 
point. At a meeting of the Louisville Clinical Society, Pro- 
fessor John A. Ouchterlony, a distinguished pathologist and 
teacher, in discussing the subject of stricture of the rectum, 
said: "I ca]l to mind a dead-house experience extending 
over many years. During the war I made post-mortem ex- 
aminations upon hundreds of cases who died of dysentery — 
the most malignant forms of the disease, as all will attest 
whose observations extend back to war times — and I can not 
remember to have ever seen a stricture of the rectum as the 
result of dysentery. In the two hospitals to which I was 
pathologist there were eleven hundred and fifty beds, and we 
sometimes made as many as Hve or six post-mortems a day. 
After the close of the war I was for many years pathologist 
to the City Hospital, but in all my dead-house experience I 
never saw a stricture of the rectum caused by dysentery." 

These are the remarks of a very close observer, and my 
experience certainly coincides with his. 

3. Tubercular. — It is evident that a tubercular condition 
is often met with in the mucous membrane and the structures 
of the rectum, and the lymph follicles of the ileum and large 
intestines are the organs usually infected when the disease 
has its origin in the intestinal tract. If stricture and ulcera- 
tion were the terms used, I could make no objection to the 
classification of tuberculosis as the cause of ulceration. That 
ulceration frequently results from this diathesis or dyscrasia 



NON-MALIGNANT STRICTURE OF THE RECTUM. 339 

no one can donbt, but that the coincident stricture follows, 
as from other well-known causes, notably syphilis, I can not 
agree. The disposition of tuberculous tissue everywhere is 
to break down. Before the capacious rectnm is filled with 
tubercular deposit sufficient to stricture it, it will have broken 
down from ulceration, etc., and it must be by deposition 
only that we can conceive of stricture from this cause, be- 
cause cicatrization is so seldom and so feeble in these parts 
that it would be the rarest accident to find it. In no instance 
have I ever seen a stricture of the oronclii as the result of 
tuberculosis. There would be just as much reason to expect 
it there, or indeed more, as in the rectum. 

4. Inflammatory. — This term is so broad and comprehen- 
sive that we must perforce of reason admit it as the cause of 
stricture of the gut — indeed, as the one grand and common 
cause — for if stricture exists from trauma, pressure, venery, 
dysentery, cancer, syphilis, tubercle, ulceration, or what not, 
it is inevitably due to the processes and products of inflam- 
mation. In no other way can a stricture be formed. 

It might be argued that a lesion or wound existing in the 
bowel by the reparative process heals and leaves cicatricial 
tissue, and that stricture is the result of the cicatrix, and not 
of plastic infiltration of the tissue proper. In answer, I would 
say that there could have been no cicatrization if there had 
been no inflammatory process ; hence, inflammation, being 
the cause of the cicatrix, was in truth the cause of the strict- 
ure. It is said that any severe form of proctitis resulting in 
ulceration may be a cause of stricture. To this proposition I 
freely assent ; but the most difficult part of the whole matter 
is to tell the cause of the proctitis, which is inflammation. It 
is not therefore to the proposition that I object, but to the 
proposed or suggested causes. For instance, in naming sev- 
eral, the following is given by some author as the cause of 
stricture : "Erosion and ulceration of hemorrhoidal tumors." 
Now, in the nature of things, how can this be true % We 
might understand how the hemorrhoidal tumor could by 
friction excite some ulceration of the bowel, or the hsemor- 



340 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

rhoid itself, being a tumor, could have its own mucous mem- 
brane injured and ulcerated. Suppose it does, how can that 
ulceration produce a stricture of the rectum ? As we have 
intimated, strictures may result from two pathological con- 
ditions — first, from a deposition of plasma causing an ob- 
struction ; second, by cicatrization causing a stricture. Can 
either of these conditions result from hemorrhoidal tumors 
being ulcerated ? I think not. The inflammatory deposit 
would only involve the tumor, and a cicatrix on top of a pile 
would not amount to a stricture. 

Traumatism. — Under this head the authors include ulcer- 
ation following operations or the cicatrizing of wounds made 
around the rectum, and cite the surgical operation done for 
hemorrhoids and fistula in ano. In all my practice I have 
never seen such result follow either operation. I can under- 
stand how a cicatrix resulting from the removal of too much 
skin from this region might cause a stricture of the anus. 
Dr. W. O. Roberts, of Louisville, has told me recently of 
operating on a patient of this kind, the original operation 
having been done by an inexperienced hand. I can not un- 
derstand how a surgeon used to operating in this region 
would do an operation that would result in a stricture of the 
rectum. These constrictions that might result at the anus 
can not properly be called a stricture of the gut ; but, as far 
as the classification goes, traumatic strictures are in fact in- 
flammatory strictures. Inflammation is the result of trauma ; 
so one class might be made to include both. For brevity this 
would be the best. 

Venereal.—'-'' Without admitting too much," says one au- 
thor, "it may be safely said that, beyond dispute, there are 
three forms of well-recognized venereal disease in the rectum 
which may result in stricture. These are chancroidal, sec- 
ondary, and tertiary ulcerations, either simple, traumatic, or 
the result of direct inoculation, and an unusual form of ter- 
tiary disease, of the general nature of gummatous deposit, 
variously described by different authors, and by Fournier as 
ano-rectal syphiloma." This author leads us to infer that 



NON-MALIGNANT STRICTURE OF THE RECTUM. 341 

these three venereal causes — viz., chancroidal, secondary, 
and tertiary ulceration — are the most infrequent way that 
stricture of the rectum can be produced, and he classifies the 
form of tertiary disease of the general nature of gummatous 
deposit as an unusual form of stricture. To the proposition 
that chancroids are responsible for stricture of the rectum I 
certainly must dissent, and that the gummatous deposit of 
syphilis is an unusual form of stricture of the rectum I 
can not admit. Allingham reports that out of seventy pa- 
tients suffering with stricture of the rectum, thirty-five of 
them had a history of syphilis. I have frequently said that 
I believed that more than one half of the strictures met with 
in the rectum were the result of syphilis, and I have also 
often asserted that in no single instance have I ever seen a 
stricture of the rectum caused by the healing of a soft sore. 
I do not believe that it can occur. The same opinion is held, 
partially at least, by Allingham, James R. Lane, Alfred 
Cooper, Coulson, Christopher Heath, and others. These 
three causes are said by many to produce their effect by sim- 
ple trauma or direct inoculation. In my opinion, it can not 
result in any such manner, and granting that the soft sore 
could produce an ulceration that might end in stricture, how, 
I would ask, can the aforesaid pus get into the rectum % It 
may have occurred, but even granting that it did, by direct 
contact, I do not believe that it would result in a stricture. 
Instead of secondary syphilis, or syphilis of the tertiary 
form, being an unusual cause of stricture of the rectum, I 
maintain that it is the usual and only form that we find this 
disease producing, or causing stricture of the rectum. Bi- 
cord, Founder, Heath, and others believe this, and Mr. Bry- 
ant, in his excellent work on the Practice of Surgery, de- 
scribed these ulcerations and strictures of the rectum as 
" mainly syphilitic," and says: " Foreign authors describe 
chancroidal disease of the rectum, venereal, but not syphi- 
litic. In this country it is hardly recognized." I certainly 
agree with this author. I desire, as a point for illustration, 
to quote a table of cases, numbering seventy, admitted into 



342 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

St. Bartholomew's Hospital, which gives the probable pri- 
mary cause of the disorder : 

Syphilis 13 

Childbirth 8 

Operation for piles 8 

Operation for fistula 2 

Congenital 2 

Inflammation of the bowels (peritonitis) 2 

Internal fistula 2 

Dysentery 2 

Tubercular disease 1 

Unassigned 30 

70 
This table was made from Cripps's notes, when Surgical 
Registrar at St. Bartholomew's, and he says in reference to 
it: "It would appear in the above table that eighteen per 
cent represents as near as possible the proportion of cases of 
stricture admitted into St. Bartholomew's Hospital which can 
be fairly assigned to a syphilitic origin." 

Now, by a careful study of this table, it can be seen that 
syphilis is likely to play a greater part than is assigned to 
it as the cause of stricture of the rectum. In the first place, 
thirteen of the cases are ascribed to syphilis. The next 
eight cases are reported as being produced by childbirth. I 
suppose the gentleman who compiled the table meant to say 
that pregnancy was the cause of the stricture that is set down 
to childbirth, for I have never yet known a case of stricture 
of the rectum to result from the latter cause, and it is very 
doubtful if pregnancy can be set down as even an infrequent 
cause for stricture of the gut. Very few cases can be traced 
to this origin ; certainly an observation of eight cases out of 
seventy, giving this as the cause of stricture of the rectum, 
is incorrect. Of course, too, the patient's testimony was 
taken in making up the opinion. The next eight cases are 
attributed to operation for piles. The most charitable con- 
struction that can be placed upon this statement is that the 



NON-MALIGNANT STRICTURE OF THE RECTUM. 



343 



patients are mistaken ; otherwise the operation for piles was 
done by very inexperienced hands, and no snch result would 
have occurred in the practice of Mr. Cripps. The same thing 
can be said of the next two cases, reported as occurring from 
the operation for fistula. Two cases are congenital. These 
of course must be ruled out in forming an idea of what aver- 




Non-malignant stricture of the rectum. (Ball.) 



age syphilis plays in the seventy cases. As causing the next 
two, inflammation of the bowels (peritonitis) is set down. 
This of course is a mistake. Internal fistulae are responsible 
for two of the cases of stricture. To say the least, this is a 
very high proportion to be observed in seventy cases. Dysen- 
tery is said to be the cause of the next two cases. As I have 
already stated, I can not believe that dysentery is a cause of 
stricture of this kind. I will not argue it here. The next 
oase is said to have had tubercular disease for its origin. 



344 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

It is fair to presume that there is a reasonable doubt in this 
case. There are # thirty cases unassigned. As I firmly be- 
lieve that syphilis is accountable for one half the cases of 
stricture of the rectum, I imagine that one half of these thirty 
cases could be traced to that cause. Therefore, instead of 
syphilis being represented by eighteen per cent in this table, 
I am constrained to believe, if their history could have been 
known positively, that fully one half of them were caused 
by syphilis. 

I have already stated that I do not hold to the theory of 
chancroidal ulceration, and consequent stricture, as advocated 
by Ziegler, Mason, Kelsey, Van Buren, Gosselin, and others. 
Nor do I subscribe to the belief that the stricture is caused 
by the contraction of the cicatrix of the healed ulcer. Cripps 
says : "I rather regard the stricture as due to the permanent 
atrophy of the circular muscular fibers of the bowel and the 
posterior border of the levator ani, an atrophy brought about 
by the prolonged reflex irritation excited by the ulcerated 
surface." 

I am equally opposed to this view of the matter, for the 
reason that I believe that strictures in the syphilitic subject 
are the result of a syphilitic neoplasm, which becomes organ- 
ized into firm tissue. It is a gummatous deposit, and the 
rectum is a favorite seat. I believe, therefore, that it is this 
form of syphilis that produces stricture of the rectum oft- 
enest. 

Diagnosis. — When the stricture is within four inches of the 
sphincter muscle it is easily diagnosticated, be it malignant, 
benign, or syphilitic ; the finger will detect it. It is a very dif- 
ferent matter, however, to determine its character, and yet to 
a certain extent the treatment depends upon it. Kelsey says : 
" There is an old and deeply rooted idea in the minds of the 
profession that a stricture of the rectum must be either can- 
cerous or syphilitic— an idea founded on error and capable of 
doing much harm and injustice to innocent people. Again 
and again I have been able to give great comfort to women 
suffering from this disease by denying the correctness of this 



NON-MALIGNANT STRICTURE OF THE RECTUM. 345 

idea in my own practice. The fact that a stricture is not 
cancerous adds little weight to the idea that it may be 
syphilitic." 

This is so diametrically opposed to my views and observa- 
tions that I desire again to say that I believe fully one half of 
the strictures found in the rectum are due to syphilis. Not 
venereal in the sense that many would have us believe — name- 
ly, by the infection of the rectum by chancrous pus, or by 
direct contact, but as a secondary deposit, the result of con- 
stitutional disease. There are but few authors to-day that 
deny this fact, but in admitting it they class these cases as 
exceptional. It is no reflection upon the morals or virtue of 
the married woman to form a diagnosis of syphilitic stricture 
of the rectum, aud I have had many cases in private practice 
where the family physician was very loath to believe that my 
diagnosis of syphilitic stricture was correct, and yet I can call 
to mind but few of the cases in which this opinion was not 
verified by the husband, after the importance of the subject 
had been explained to him. By a late estimate it is said 
that over five million people in the United States are sub- 
jects of constitutional syphilis. If it is admitted that one 
single case of stricture of the rectum can result from this 
constitutional disease, it admits the argument. Then, taking 
into consideration the great number affected with it, is it 
any wonder that we should have the percentage named as 
suffering from this manifestation in the rectum ? I have long 
since been forced to believe that the rectum is a favorite 
seat for syphilis, and, because this is not generally recog- 
nized, these cases escape notice. Mr. Allingham, in tabu- 
lating his cases of stricture, says: " Thus, out of the total 
number of ninety-nine patients, fifty-two or more were syphi- 
litic." As a means of diagnosis, the clinical history and ob- 
servation of the case has much to do with forming a cor- 
rect opinion. If it is ascertained that the patient has con- 
stitutional syphilis, I would consider that it was a strong 
point gained. I do not wish to be understood as saying 
that in every case where both syphilis and stricture exist, 



346 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXUKE. 

the latter was caused by the former, but undoubtedly in the 
vast majority of cases this is true. Indeed, so firm am I in 
this belief that if it is a question between cancer or no can- 
cer, and it is decided that it is not malignant, ninety-nine 
out of every hundred cases will, in my opinion, prove to be 
syphilitic, for the reason that stricture, the result of benign 
ulceration, does not resemble in the least stricture from ma- 
lignant deposition. To the contrary, syphilitic stricture does, 
to a degree, resemble malignant growths. To be plainer, 
malignant disease and syphilitic disease invade the rectum 
as a deposit and infiltration of the submucous tissues, etc. 
Ulceration here is secondary to the deposit, and is caused by 
the friction of the passage of faeces, or the breaking down 
of tissue, the result of the disease. Benign or simple ulcera- 
tion begins with the damage done to the mucous membrane, 
and the infiltration is secondary to it, unlike both malignant 
and specific disease. Besides, a simple stricture is generally 
annular, and does not consist of a deposit in the submucous 
tissues. I do not wish to convey the idea that ninety-nine 
out of every hundred cases of stricture of the rectum are 
syphilitic by any means, and I have been thus explicit be- 
cause I have been quoted wrong in this matter a number of 
times. Ball, of Dublin, in his excellent work on the diseases 
of the rectum and anus, says : " There is no part of the body 
in which connective tissue is present in which the gummy 
deposit, so characteristic of the later stages of syphilis, may 
not be found ; and we find that the lower bowel and anus 
prove to be no exception to this rule." Cases proving that 
syphilis attacks the rectum in a gummatous way are rec- 
orded by Leisol, Molliere, Verneuil, Barduzzi, Zappula, and 
many other noted authorities. So of the truth of the propo- 
sition no one can doubt, and I am sure that if a careful record 
of cases be kept by those interested in this subject, especially 
of their hospital and infirmary patients, it will soon be evi- 
denced that syphilis is the greatest of all known causes for 
stricture of the rectum. For the last twelve years I have 
been connected with the Louisville City Hospital, in the ca- 



NON-MALIGNANT STRICTURE OF THE RECTUM. 347 

pacity of either visiting or consulting surgeon, and have had 
under observation a large number of the demi-monde, and my 
record book will show a large proportion of these as suffering 
from syphilitic stricture of the rectum. Syphilitic stricture 
can be diagnosticated from cancerous stricture by taking into 
consideration the clinical history of the case. In the major- 
ity of instances a syphilitic history can be traced. I have 
quoted Allingham as saying that there was something pecul- 
iar about the feel of cancer which the operator's finger rarely 
mistakes even for simple indurated ulceration. I have also 
said that I have failed to detect that peculiar or, as described 
by some, that gritty feel of cancer, and yet I must agree with 
Allingham that it is a fact in some cases that the feel is pecul- 
iar ; but if I were called on to describe it I could not. If, 
however, the cancerous mass is imbedded in the submucous 
tissues, a hard and nodular feel will be evidenced to the 
finger. In syphilis the induration is more even and extends 
with more regularity, and after a time is of a fibrous char- 
acter, and is so indicated to the touch. There is not much 
difference as evidenced to the touch of a cancer of the rec- 
tum at this particular stage and the same character of cancer 
in the woman's breast. After ulceration has occurred, in the 
latter stages of the two diseases (syphilis and cancer), the 
diagnosis by the feel can be more plainly made out. At this 
stage cancer is more liable to break down. Syphilis is more 
liable to build up and become more fibrous in nature, if 
possible. At this time cancer is more apt to yield to the 
finger, and when it is pushed through the cancerous mass or 
stricture the breaking down is very perceptible. In the close 
stricture from benign causes, or syphilis, the opposite is true, 
because it is unyielding. We sometimes lay too great stress 
upon the disposition of the malignant growth to bleed. Al- 
though this is called attention to by many authors, it is cer- 
tainly not true in the early stages, before the mucous mem- 
brane is involved ; but in the advanced stage it must be 
believed that the mass could more readily bleed than the 
ulceration of a gummatous deposit. The swollen or enlarged 



348 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

glands in the inguinal region can not be taken as a positive 
sign or indication of cancer, from the fact that they are 
swollen in many cases of benign ulceration and inflammation, 
and also from syphilis. Then, too, I have seen stricture of 
the rectum from syphilis just as painful as that caused by 
cancer. Syphilitic ulceration and stricture can be diagnosti- 
cated from simple ulceration by the feel or touch. In the 
cases of simple ulceration the constriction, as I have said, is 
usually annular, and often involves only the mucous mem- 
brane, as, for instance, when a stricture is caused by long- 
continued pressure. I wish again to say that as a method 
of diagnosticating stricture of the rectum, I object to the use 
of rectal bougies, especially those made of metal or hard rub- 
ber, and to all other instruments suggested for that purpose. 
They are exceedingly dangerous, especially in strictures lo- 
cated high up, whether they are caused by malignancy or 
are non-malignant. It is a well-known fact that the common 
seat of stricture is within the reach of the finger, and it is 
the rarest case to find one in the movable gut ; therefore it 
is with the finger and not with instruments that they should 
be detected. 

Symptoms. — The early symptoms of stricture of the rectum 
are very obscure and confusing. The great trouble is that the 
early symptoms are so masked or entirely nil that no atten- 
tion is paid to them by the patient, but when he is forced to 
consult a physician a very decided stricture may exist. The 
changes made manifest in the rectum are those of a gradual 
deposit in the tissues of the morbid material, which goes on 
so slowly and insidiously that for a long time there are really 
no symptoms. I have seen many cases where the first symp- 
tom noticed was a so-called constipation (obstipation would 
be a better word), and upon the introduction of the finger a 
tight constriction could be felt. This may apply to any form 
of stricture. The first symptoms of stricture, then, are not 
the discharge of bloody pus, etc. , indicative of ulceration that 
some describe. Therefore I must diifer from those who place 
the symptoms of ulceration first and those of constriction 



NON-MALIGNANT STRICTURE OF THE RECTUM. 349 

afterward. Indeed, I have often seen the rectum nearly com- 
pletely blocked by a deposit without any ulceration at all. 
Ulceration can not take place and be accompanied with the 
symptoms incident to it — as a discharge of blood, pus, or 
mucus and pus — until the changes of inflammation have been 
such or the friction has been so great that the mucous mem- 
brane and submucous tissues have undergone that change 
which constitutes ulceration. When this latter condition is 
established we have the characteristic signs — diarrhoea, flatus, 
muco-purulent discharge, or rather muco-bloody discharge 
first, succeeded eventually by purulent discharge and alter- 
nating diarrhoea and constipation ; the bearing-down sensa- 
tion, together with tenesmus, reflected pain to the back and 
down the thighs, irritation of the kidneys and bladder, an 
uncomfortable feeling always about the rectum, the passage of 
small bits or tape- like actions, are all indications of the dis- 
ease. I am persuaded that oftentimes stricture of the rectum 
is diagnosticated by the "tape-like" action, when in reality 
the molding is done by the sphincter muscle in an irritable 
state and that no stricture in reality exists. I am satisfied, 
too, that many cases of so-called chronic constipation are due 
to the narrowing of the lumen of the gut by syphilitic de- 
posit. The same thing can be said of cancer or of simple 
stricture. This has occurred so often in my practice that I 
am now in the habit of examining the rectum in every case of 
chronic constipation. This same rule holds good in cases of 
supposed dysentery, for, as I have observed, dysenteric dis- 
charges are frequently only a symptom of stricture and 
caused by it. I have had but two cases of acute obstruction 
caused by the prolonged existence of a stricture of the rec- 
tum — one in the case of a young lady, who failed to report 
to me as often as necessary for dilatation of the stricture (she 
would not consent to an operation), and during a summer out- 
ing took sick and died from an acute obstruction ; the other 
was a young married woman, the case occurring in the prac- 
tice of one of our local physicians. I divided the stricture 
with the knife and relieved her. 



350 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

Acute obstruction as a symptom of stricture I have never 
seen but once. The case has been reported in the chapter on 
cancer as occurring in the practice of Dr. H. H. Grant, of 
this city. I have examined a number of patients who com- 
plained of constipation only, who, upon being examined, re- 
vealed a decided stricture that the smallest finger could not 
pass, and yet evacuations were had through this. It is truly 
wonderful to see patients who have strictures of a very small 
caliber, who seem to enjoy perfect health, and whose physical 
proportions and development are not hurt in the least. It 
must not be forgotten, however, that these are dangerous con- 
ditions and constantly imperil the life of the patient. 

Treatment. — In considering the treatment of this very for- 
midable condition I shall adhere in the strictest sense to the 
pathological changes that have taken place in the bowel 
which constitute a stricture. This therefore rules out the 
treatment of proctitis or the subsequent ulceration, which is 
one cause of stricture, and brings us directly to the means of 
treating that which is the result of said causes. It must be 
granted that many times ulcerations which would eventuate 
in stricture are cured before that condition results. This can 
not hold good in cancer. Can it in syphilis ? I know that 
authors report a number of cases of syphilitic ulceration of 
the rectum cured without consequent stricture, but in my ex- 
perience this has been a very difficult thing to do. In the 
great majority of cases we are confronted at the onset with 
stricture, not with ulceration, so insidious is the disease, and 
in annular strictures resulting from simple inflammation of 
the mucous membrane the physician will frequently be called 
to treat the stricture and not the ulceration which produced it. 

The methods practiced to-day for treating stricture of the 
rectum are: 1. Dilatation. 2. Incision. 3. Electrolysis and 
raclage. 4. Excision. 5. Colotomy. Of course, under the 
division I have made, we rule out general treatment. 

Dilatation.— Kelsey, in speaking of dilatation, says : " By 
dilatation I mean gradual stretching, not forcible divulsion," 
and adds that the latter is seldom applicable. Dr. Wilier 



NON-MALIGNANT STRICTURE OF THE RECTUM. 351 

Van Hook, in his conclusions on the treatment of non-malig- 
nant rectal strictures, says: "Most valve-like strictures are 
amenable to treatment by gradual dilatation. Some of the 
annular strictures are sufficiently distensible to be relieved by 
gradual dilatation, but this treatment must, in this form of 
malady, be kept up indefinitely. Treatment by gradual dila- 
tation prolonged indefinitely, as is usually necessary, must 
be tolerated only when relief is complete and when the pa- 
tient is sufficiently intelligent to comprehend its importance. 
Forcible dilatation or divulsion is dangerous and should be 
abandoned." 

Dr. Louis Bauer, in commenting upon the position I took 
in the general address on surgery before the American Medi- 
cal Association in regard to the division or forcible divulsion 
of stricture of the rectum, says in the St. Louis Clinique : 
"The preliminary division of the stricture, as Dr. Mathews 
suggests, is certainly good practice ; but whether divulsion or 
dilatation is to follow should depend upon the anatomico- 
pathological condition of the gut above the stricture. The 
use of bougies is appropriately repudiated by the author, his 
objections being well sustained by numerous fatal accidents 
from perforation of follicular ulcerations. The same patho- 
logical conditions which are frequently met with in stricture 
preclude, likewise, forcible divulsion." 

To these views, expressed by the distinguished gentlemen, 
I must dissent. In replying to the quotation from Kelsey, I 
would say that I believe that gradual dilatation of stricture 
is objectionable, first, because, as Van Hook says, it must be 
kept up indefinitely ; second, for the reason that by this 
form of treatment a continual irritation exists, more plasma is 
thrown out, and the strictured surface is increased. It may 
be true that some temporary relief is afforded the patient, but 
upon the recontraction of the tissue, which is sure to take 
place, we have lost more than we have gained. I believe 
that the pathology of stricture of the rectum from simple in- 
flammation is very much like stricture of the urethra, and I 
believe with Otis that division of strictures in the urethra 



352 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

shows much better results than treatment by gradual dila- 
tation. I can not hold to the view that by the frequent 
passing of bougies through the strict ured surface absorption 
of the tissues is caused. I believe, to the contrary, that the 
converse is true. To Yan Hook's statement — that "most 
valve-like strictures are amenable to treatment by gradual 
dilatation" — I would say that, even admitting this premise, I 
would divide this valve-like constriction in preference to 
dilating it gradually. In the first place, I can see no danger 
in dividing this form of stricture. In the second place, by its 
division we accomplish in one minute what it will take an 
"indefinite time " to accomplish by gradual dilatation. Now, 
it will be remembered that these strictures are fibrous bands, 
and it would be very much like stretching an India-rubber 
ring ; as long as the dilator was in it, it would be expanded ; 
the moment you take it out it recontracts. But it is a very 
different thing to draw your knife through the rubber ring. 
It will remain expanded. So in this annular constriction of 
the gut ; you may stretch it to-day, but next week it will 
have come back to about its usual size, unless, as the author 
says, it is kept up "indefinitely." To the contrary, if you 
cut through this fibrous ring, it is more apt to remain uncon- 
tested. I quite agree with Van Hook when he says the 
treatment by gradual dilatation of stricture of the rectum 
must be prolonged indefinitely ; but, as far as my experience 
goes in this plan of treatment, a better term to use, which is 
more to the point, would be, prolonged forever. He admits 
that in the different varieties of stricture, including the valve- 
like, annular, etc., this course of treatment must be kept up. 
I beg to quote in this connection a letter received from Dr. 
John P. Bryson, of St. Louis. 

" St. Louis, May 23, 1891. 

"Dear Dr. Mathews: I was much pleased to note in 
your Washington address on rectal stricture that the general 
trend of your researches led you to the view which seemed 
to compel an exclusion of all other so-called factors, leaving 
only inflammation as the essential one. For some years past 



NON-MALIGNANT STRICTURE OF THE RECTUM. 353 

I have been greatly interested in the study of the aetiology 
and pathogenesis of stricture of all organs, with a view of 
evolving some general principles applicable throughout — this, 
of course, in immediate connection with urethral stricture. 
For the importance of such study and its influences on our 
efforts at radical cure, I think surgeons are entirely too neg- 
lectful. A full appreciation of it seems to me to be the key 
to the situation. I think that, cceteris paribus, the essential 
factor in all strictures is the same. I hope you will read a 
reprint which I send you by mail, and tell me some time 
whether there would be any objection to chronic contracting 
periproctitis (or proctitis) as a definition of rectal stricture, 
and whether there is not good reason to believe that it is 
essential that a lesion of the epithelial lining should first take 
place. You will also observe from the reprint that I am 
heartily in accord with you in the matter of excluding con- 
genital conditions, cancer, etc., as either causing or being 
strictures. Very truly yours, 

"John P. Bryson." 

As the purport of this letter is so appropriate to the sub- 
ject under discussion, I have quoted it in full. I have already 
said that I believed there was a certain analogy between strict- 
ure of the urethra and stricture of the rectum, or, as Dr. Bry- 
son intimates, strictures, in whatever locality, must have more 
or less the same aetiology . Therefore I have taken occasion 
to mention valve-like strictures and annular strictures as fall- 
ing under the head of strictures by the inflammatory product, 
which are analogous to strictures of the urethra-, and should 
receive the same treatment. That "only inflammation is the 
essential one," so far as the factors are concerned, in the 
stricture, can not be denied. But to the question "whether 
there would be any objection to chronic contracting periproc- 
titis, or proctitis, as a definition of rectal stricture," I must 
say that it depends entirely upon circumstances. I do not 
believe that proctitis per se produces rectal stricture, except 
of the character named — viz., valve-like or annular strictures, 

23 



354 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

or, in other words, that the mucous membrane is made to 
form the constriction by the inflammatory act and not by 
deposition proper, as will be observed in other forms, notably 
cancer and syphilis. In the two latter instances we have a 
constricted surface established by the deposition of morbid 
material, beginning usually in the submucous tissues. By 
this constant building process the rectum becomes filled up 
or occluded. Therefore I do not think it necessary in these 
cases that a lesion should exist, but maintain that ulcerations 
are secondary to the condition. But to the variety which 
bears an analogy to urethral stricture, I am sure that Dr. 
Bryson is correct when he maintains that a lesion is the start- 
ing-point, and is necessary to the formation of stricture. I 
am glad that so able an authority agrees with me that it is a 
better plan to lessen the so-called causes of stricture and em- 
brace them under a general head. Dr. L. Bolton Bangs says, 
in a late article contributed to the Medical News : " Gradual 
dilatation is sufficient for soft, non-fibrous strictures of the 
posterior urethra, and of those of similar pathological struct- 
ure in the bulbous stricture. It is also sufficient in some of 
the soft, not well- organized strictures in the penile urethra 
that are practically simple adhesions (?) of the surfaces of the 
mucous membrane ; but for the organized strictures I believe 
that some form of urethrotomy is preferable." 

I am so thoroughly in accord with Dr. Bangs on this sub- 
ject that I must say that if we meet u soft, non-fibrous strict- 
ures," or those of a similar pathological structure, in the rec- 
tum, I might believe that gradual dilatation would effect some 
good ; but it will be noticed that he says, " but for the organ- 
ized strictures, I believe that some form of urethrotomy is 
preferable." So I say about organized strictures of the rec- 
tum. Gradual dilatation may do for the nonce, but, to effect 
any cure or permanent good, division of this organized strict- 
ure is necessary. Why forcible divulsion is seldom appli- 
cable, as Kelsey says, I can not understand. If a fibrous 
stricture exists, I am sure that forcible divulsion, or divis- 
ion, is the best method, for we do in a few minutes by this 



NON-MALIGNANT STRICTURE OF THE RECTUM. 355 

means what it would take weeks or months or an "indefinite 
time " to accomplish by gradual dilatation. Therefore I must 
confess that I put but little stress, or no stress at all, upon 
treating stricture of the rectum by bougies. Iu fibrous strict- 
ure it accomplishes but little good, and in the malignant one 
it would be dangerous. To the assertion made by Dr. Bauer 
— "but whether divulsion or dilatation is to follow should 
depend on the anatomico-pathological condition of the gut 
above the stricture" — I certainly agree. And in taking ex- 
ception to my practice when he says "divulsion as proposed 
by Dr. Mathews in the case reported by him to the State 
Medical Society of Kentucky in 1878 would have torn the 
rectum of my patient into tatters," I desire to state, as I 




c 

Divulser for stricture of the rectum. 

stated in my article, that in this one particular case I had to 
accept one of two alternatives — colotomy or divulsion. The 
patient appeared to be approaching a condition of extremis, 
and had a large abdomen ; and, under the circumstances, I 
believed that it was preferable to try to break down the strict- 
ure which was found at the entrance of the sigmoid flexure. 
"That it did not tear the rectum of my patient into tatters" 
is evidenced by the fact that he recovered from the operation 
and lived for a number of years. But I wish again to assert 
that the point taken by Dr. Bauer is a very excellent one— 
that the pathological condition above the seat of stricture 
should be considered before divulsion is attempted ; but, as 
he seemed to misunderstand my position in the subject, I 
wish to say here that I practice the divulsion and incision 
plan upon strictures of the rectum located within a finger's 
length from the external sphincter muscle, and it will be 
readily seen that the anatomical bearings to which Dr. Bauer 
refers are in my favor, from the fact that there can be no dan- 



356 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ger of tearing the rectum at all, for these strictures are located 
in the fixed portion of the gut. Indeed, I have always main- 
tained, and have so said in this chapter, that no dilatation of 
a stricture should be attempted when located in the movable 
part of the rectum, and the instance that I cited was one sur- 
rounded by rare circumstances, and was considered a dernier 
res sort. So, between Dr. Bauer and myself, there can be no 
material difference of opinion. To Van Hook's eighth con- 
clusion — that "forcible dilatation or divulsion is dangerous 
and should be abandoned" — I would say that I have been 
practicing this method for strictures of the rectum located 
within three and a half inches of the sphincter muscle for the 
past fifteen years, and that I do not consider it dangerous in 




Dilator for stricture of the rectum. 

the least ; and therefore I argue that it should not be aban- 
doned. I have already given my reasons for preferring this 
method to gradual dilatation, so I have only to say that my 
experience teaches me that I can get much more satisfactory 
results from dividing or divulsing strictures of the rectum 
within the measurement named than by gradual dilatation ; 
and I would add that, if the strictures are located higher up 
in the movable gut, then I do not think either division, forci- 
ble or gradual dilatation advisable, for the reasons assigned 
by Dr. Bauer— viz., that it might possibly tear the rectum 
into tatters. 

Incision.— I am very partial to incision or incisions for 
the relief of stricture of the rectum. Of the two operations 
recommended, internal and external posterior linear proc- 
totomy, I much prefer the internal, recognizing at the same 
time that I differ from many distinguished authorities. It is 
urged for the external, which consists of not only going 



NON-MALIGNANT STRICTURE OF THE RECTUM. 357 

through the strictured surface, but also in dividing the 
sphincter muscle, etc., that it is all-important to get the 
necessary drainage. I do not think so, and if I did, I believe 
the ill effects of dividing the sphincters outweigh the matter 
of drainage. I can not believe either that the internal incis- 
ion is as dangerous as it is represented to be by some authors. 
In speaking of the two operations Van Hook says : " 1. Inter- 
nal proctotomy leaves a wound exposed to infection without 
proper dressings or drainage, and should be regarded as dan- 
gerous. 2. External proctotomy is a valuable temporizing 
measure, giving free outlet to faeces and pus, and allowing 
the patient to recuperate in general health so as to bear a 
radical operation." 

In reply to this, I would say that it depends very much 
upon how the internal operation is done, whether it leaves 
the wound exposed to infection or not. There are many 
strictures found in the rectum which require a division of the 
fibrous structure only, and therefore, as none of the deep 
tissues are involved, it can not be argued that the dressings 
or drainage are so absolutely necessary. Indeed, I am con- 
vinced, in dealing with stricture of the gut, that it is not 
often necessary to make this deep cut back to the sacrum at 
all. If such necessity arises, then I would concede that ex- 
ternal proctotomy would be the better of the two operations. 
My plan for doing internal proctotomy is as follows : 

I introduce a speculum of small caliber through the open- 
ing in the stricture, and stretch the structures to a moderate 
degree. I then secure the instrument and, taking a long, 
sharp knife, I divide the constrictions of fibrous tissue down 
to a healthy base. This first cut is made in the median line ; 
but often I am not content with one cut, therefore I make 
several, around the circumference of the gut. I then place a 
tampon, through which I have inserted a metallic tube for 
drainage and the escape of gases in the rectum. This tam- 
pon is aseptic, and usually dusted with powdered persulphate 
of iron. On the fourth day it is removed, and the rectum 
irrigated with a mercuric solution. If the operation is done 



358 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

effectively, I have never seen the necessity of employing a 
bongie afterward for the purpose of dilatation. Patients are 
averse to their use, and, in my opinion, they do not accom- 
plish the good claimed for them. My objection to the exter- 
nal operation, although I have practiced it often, is that to 
divide the sphincters when all the tissues are in a diseased 




Prince's obturator. 

condition invites non-union, and incontinence is nearly cer- 
tain to follow. The suggestion of Weir — to confine the incis- 
ion to the stricture, and then to drain the incision by a tube, 
brought out through the skin at the tip of the coccyx — I do 
not think will accomplish the purpose in many cases ; be- 
sides, it leaves a channel which may not heal. To divide the 
sphincters, and then employ three or four deep provisional 
wire sutures between the anus and the strictures, leaving 
them loose and stuffing the incision with charpie, after the 
manner of Kelsey, I think unwise. It is said that one great 
danger of the operation is septic periproctitis, but under 
antiseptic precautions the danger, in my opinion, is reduced 
to a minimum. In one case of malignant disease, in which 
I did the external operation, rapid sepsis took place, and the 
patient died in twenty-four hours. I do not think either the 
internal or external operation should be done for malignant 
growths, unless total, or nearly total, occlusion has taken 
place. In all cases of non-malignant stricture, syphilitic or 
simple, either the internal linear proctotomy of the French 



NON-MALIGNANT STRICTURE OF THE RECTUM. 359 

surgeons, or the external operation as practiced by many, is 
far more preferable, in my opinion, to either excision or co- 
lotomy, simply for the reason that these patients are seen at 
a late date when constitutional infection exists, and we can 
expect but a palliative effect from either one of the operations. 

Van Hook says: "The uncomplicated annular contract- 
ures, not amenable to gradual dilatation, and the tubular 
strictures below the peritoneal limit are permanently curable 
by Pean's method of modified amputation, and occasionally 
(but with much uncertainty) by posterior linear proctotomy. 
I must say that Pean's method has never been looked upon 
with much favor by men who are in the habit of dealing 
with these pathological conditions. It would depend very 
much upon the character of stricture that we are dealing 
with whether we should think of the operation at all. In 
uncomplicated annular contractures of which the last author 
speaks, I would think it out of the question to consider 
Pean's method, for the reason that any contraction not com- 
plicated can be more easily and much more certainly treated 
without serious defect by the method proposed. It must be 
remembered that in doing Pean's operation we sacrifice the 
external sphincter muscle, and I must submit that I have 
never yet seen a case of an uncomplicated annular contrac- 
tion of the rectum but that I would regard a much less seri 
ous pathological condition than the loss of the sphincter 
muscle would occasion. 

In doing internal proctotomy, I have never had to deal 
with any of the conditions that are said to supervene upon 
the operation. My cut is not so deep as to make a receptacle 
for the discharges, and drainage has usually been accom- 
plished by means of the tube, aided by the injections into the 
rectum. Van Hook, in his sixth conclusion, says: "Cases 
of stricture complicated by ulcers or fistulse must usually be 
simplified by a preliminary posterior proctotomy and scrap- 
ing out of fistulse before the radical operation is attempted." 
I must confess my inability to see how a posterior proctotomy 
can simplify a case of this kind, and the author's idea of 



360 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

scraping out fistula? I can not comprehend. Let us take a 
case for illustration, after the nature of the one he has sug- 
gested. 

A patient presents with a stricture of whatever kind, lo- 
cated, say, two inches within the rectum. We are to pre- 
sume that it has closed sufficiently to prevent the free pas- 
sage of fasces, and in consequence the mass is retained, more 
or less, above the constriction. As the result of this an ul- 
ceration takes place which excites to the formation of fistu- 
lous tracts, and the patient presents himself for examination 
and treatment. Now, if we follow the directions as indicated 
by the author, we will first do a posterior proctotomy, which 
consists in cutting down through the stricture to its very 
base, going through the tissues to the sacrum and extending 
the incision outward, dividing the sphincter muscle. I would 
ask how this " simplifies" the case. It certainly has done 
nothing to aid in the healing of the fistulous tracts, and has 
not accomplished in any manner the simplification of the 
radical operation which is to follow. Along with the pos- 
terior proctotomy, he says that the fistulas must be scraped 
out. How and in what manner he does not state. Cer- 
tainly scraping their internal openings would accomplish no 
good, and it would be impossible to scrape the inner surface 
of tracts without first freely laying open each and every one 
of them, and in so doing we have established many wounds, 
perhaps of enormous size, around the rectum. Neither does 
the author indicate at what stage after this the radical opera- 
tion is to be performed. My experience has been with fistulas 
that are caused by a strictured condition of the gut, that they 
run in many directions and devious ways. That in laying 
them open we institute a trouble far more serious than the 
one that exists. I think the proper plan would be to dilate, 
if you will, the stricture first, either gradually, forcibly, or 
incise it, and trust to this effort to stop the progress of fist- 
ulas. I am sure that surgeons will bear me out that these 
are an unfortunate class of patients, and that but little good 
can be accomplished by doing the operation for fistulas result- 



NON-MALIGNANT STRICTURE OF THE RECTUM. 361 

ing from stricture, and certainly if we had done posterior 
proctotomy, laid open and scraped all the fistulous tracts in 
this imaginary case, we should have made this suffice, and 
not have considered the radical operation at all. 

Electrolysis. — It does appear that where we can go ef- 
fectually through a stricture by linear proctotomy at one sit- 
ting, it would be useless to attempt so slow a process as 
electrolysis. After a careful review of the subject, I can not 
believe that any benefit obtained is brought about by the 
dilatation from the electrodes used, as suggested by some. If 
there be a benefit in fact, it must be attributed rather to what 
is claimed for it— partial destruction of tissue by cauteriza- 
tion. To claim radical cures by this method, I must admit, 
seems untheoretical, if not unsurgical, and yet Dr. Robert 
Newman, of New York, and others, report many cases of 
stricture cured by this method. As this subject has received 
considerable notice by eminent medical men, including such 
names as Robert Newman, George H. Rohe, William C. Wile, 
and others, I desire to refer to this method of treatment of 
stricture of the rectum, and, in order that I may do so cor- 
rectly, I shalt quote from one of Dr. Newman's articles. 

" Instruments. — The treatment applied is virtually the 
same as in stricture of the urethra. The armamentarium 
consists of a good galvanic battery with conducting cords, 
handles with sponge electrode, a few binding screws, a set of 
rectal electrodes of different size and shape, and a milliam- 
peremeter to measure the electric current. The electrodes 
have at one end a metal bulb ; copper or brass, silver-plated 
or nickeled, is best. The form is flat or round, the latter more 
egg-shaped. They are made in sets of different sizes. The 
length is from one fourth inch to one and one fourth inch, 
and the circumference from one and an eighth to three 
inches. The stem of the electrode, except at the extremities, 
is insulated with hard or soft rubber ; some are flexible, 
others stiff. If larger sizes are needed, I use metallic bulbs, 
similar in shape and size to a vaginal electrode, which are 
from three to Hive inches in circumference. 



362 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

"Modus operandi. — The patient may be placed in Sims's 
position on the left side, bnt in the majority of cases the 
lithotomy position on the back is preferable, because in the 
examination and operation the anatomical relations of rectum 
and colon with the sigmoid flexure can be better appreciated. 
The galvanic battery is brought into action with the switch 
at zero. The sponge electrode, wet with warm water and 
connected with the positive pole of the battery, is placed 
firmly in the patient's hand, but in some cases may be pressed 
on the abdomen. The negative metal electrode is lubricated 
with glycerin and inserted per anum to the seat of the strict- 
ure, and only then the electric current is slowly increased from 
zero, cell by cell, till the desired strength is reached, which is 
ascertained mostly by the sensation of the patient. The 
strength of the current allowable varies from five to fifteen or 
even twenty milliamperes, according to the seat of stricture, 
the nature of the neoplasm, the size of the electrode, and the 
susceptibility of the patient, the rule always being not to 
use a strong current if a weak one will accomplish the object. 
The seance may last from five to fifteen minutes. No force 
should be used ; the electrode should be kept steadily against 
the stricture, and only guided ; the electrolysis does the work 
by enlarging the caliber, and then the instrument passes the 
obstruction. At the end of the seance the current is reduced 
slowly, cell by cell, to zero, and not until then is the elec- 
trode to be removed. It will be perceived that the occasion- 
ally stronger current in this operation is the only difference 
for the treatment for urethral stricture. Seances may be re- 
peated in one or two weeks. According to circumstances 
and complications of the disease, some modifications of the 
treatment may be called for, one of which is the use of 
needles in the mass of the stricture instead of the metal bulb 
at the negative pole. My small electrodes are very flexible 
and long, the object being that undue force is impossible 
while being used. The instrument also will accommodate 
itself to the flexure and easily enter the colon, thereby in- 
creasing the field of observation." 



NON-MALIGNANT STRICTURE OF THE RECTUM. 333 

Whatever might be my opinion of the use of electrolysis 
in the treatment of strictures generally, or of the stricture of 
the rectum in particular, I could not agree with the author 
that the field of observation would be increased by the instru- 
ment accommodating itself to the flexure and the colon. If 
strictures were observed in these parts, it certainly would not 
be advisable to try to treat them by the electrode. The sub- 
ject of electrolytic decomposition of organic tissues is under 
discussion, and whereas I am inclined to think that organic 
tissue will more or less yield to electrolysis, I am not yet 
quite sure of its applicability in the rectum. The following 
are Dr. Newman's conclusions : "1. Electrolysis in the treat- 
ment of strictures in the rectum is not a panacea ; on the con- 
trary, failures may happen, and probably will, if the stricture 
is due to carcinoma. 2. Electrolysis will give improvement 
to the stricture when all other methods have failed. 3. Elec- 
trolysis will cure a certain percentage of cases without re- 
lapse and without the necessity of an after-treatment or 
using bougies. 4. The best chances for a cure are through 
the fibrous inflammatory stricture." 

Having no personal experience with this method of treat- 
ing a stricture of the rectum, I am not prepared either to ad- 
vocate or disprove the statements made. 

Excision. — In speaking of the amputation of the rectum, 
I think it would be better to employ the word extirpation in 
lieu of excision. Excision of the rectum conveys but little 
idea of the operation. I can not appreciate the idea of ex- 
cising a benign stricture, not from any serious doubt as to 
whether it could be done or not, or of any dangers attending 
the operation, but there are methods so much simpler in their 
nature for the relief of these strictures that I can not conceive 
of the necessity of the radical operation. Of all evil conse- 
quences that could possibly befall a patient that had under- 
gone an operation for rectal trouble, incontinence of faeces is 
the worst. Therefore, in considering the treatment of strict- 
ure of the rectum by excision or extirpation, we must consid- 
er the loss of the function of the sphincter muscle. 



364 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

Colotomy. — In dealing with cancer of the rectum I take the 
position that the strictures resulting therefrom could not be 
considered as strictures from a legitimate standpoint, and 
therefore any method that looked to their treatment could 
only be considered palliative in that the disease went on in 
its destructive course ; but in strictures other than malignant 
the proposition is a very different one. Therefore I would 
propound a question in order to make myself better under- 
stood : Is colotomy to be recommended as a procedure at all 
in the treatment of stricture of the rectum % I unhesitatingly 
answer Yes, although in a consideration of cancerous stricture 
I hold the proposition of colotomy in abeyance. Whenever 
a stricture other than malignant is located in the movable 
part of the gut, or in the sigmoid flexure, either causing total 
obstruction or about to cause it, colotomy should be done. 
If, then, I am asked why in this instance, and not in cancer- 
ous stricture, I would answer that in doing the operation un- 
der these circumstances we prolong life indefinitely. Indeed, 
I see no reason why one should not live out his allotted days, 
or at least live for many years, after the colotomy is done for 
a benign stricture. A fibrous stricture in the locality named 
would likely cause death by occlusion if let alone. It is be- 
yond reach for either dilatation, division, or excision. There 
is nothing in the stricture per se to cause death, and a fatal 
result would only occur in the manner mentioned. It acts 
after the manner of a foreign body, causing obstruction ; can 
not be reabsorbed, and does not cause death by infection of 
the body. The constriction having blocked the channel of 
the bowel, we open a gateway above for the escape of fseces, 
and thereby prolong life indefinitely. To do the operation 
for cancerous stricture the disease is neither stayed nor cured. 
To the contrary, in benign or syphilitic strictures the patient 
will live to thank you for saving his life. If, then, it is de- 
cided to do colotomy, which of the two operations is pref- 
erable, the lumbar or extraperitoneal, or iliac or intraperi- 
toneal % I think the anatomical phrase used in designating 
the two should decide it. An operation extraperitoneal is 



NON-MALIGNANT STRICTURE OF THE RECTUM. 365 

certainly to be preferred to one that is intraperitoneal, as I 
believe that it is safer not to open the peritonaeum than to 
open it. Still I wish to reiterate that in cases of obstruction 
of the rectum or sigmoid flexure, outside of cancer, the in- 
guinal operation has some advantages if we are not to con- 
sider the opening of the peritonaeum. The methods of doing 
the two operations are described in another chapter. 



CHAPTER XVI. 

CANCER OF THE RECTUM. 

Cancer is the most formidable disease that is met with 
in the rectum. There is so much difference of opinion in 
regard to its pathology that I sometimes think that the older 
surgeons were correct, in a practical way at least, in making 
the term malignant synonymous with cancer. We very well 
know that there are some forms of tumors that reappear after 
extirpation that are called simple ; and yet when tumors have 
a tendency or a disposition to attack neighboring glands, 
or to reappear after they have been once removed, they are 
very suspicious indeed. That was a quaint description of 
cancer given by Lorenz Heister in 1731, in which he says : 
"When a scirrhus is not reabsorbed, can not be arrested, or 
is not removed by time, it either spontaneously or from mal- 
treatment becomes malignant, that is, painful and inflamed, 
and then we begin to call it cancer. " We are amused at this 
homely definition by the old master ; but when we stop long 
enough to think, we can honestly ask ourselves how much 
beyond this have we advanced in the study of this much- 
dreaded disease? Even with our much- vaunted knowledge 
of anatomy, histology, and pathology, the most learned of us 
call a halt before pronouncing upon the character of tumors, 
drawing the line, as it were, between benign and malignant 
growths. In a very notable case not long ago the daily press 
heralded one day the information, taken from the doctor's 
bulletin, that a crown prince had a warty excrescence in his 
throat ; the next cablegram, that it was a cancer. We remem- 
ber, in the history given us concerning the distinguished 



CANCER OF THE RECTUM. 367 

man's affection, that a specimen of the growth was submitted 
to a learned microscopist that the disputed question might 
be settled. I dare say that there is not a surgeon but has 
been deceived by the verdict of the microscope in such cases, 
and I have sometimes thought that the physical signs and 
clinical history were of much more value in determining the 
nature of suspected tumors than anything that the micro- 
scope can reveal. That the cells have proved inefficacious, 
the alveolar formation not a certainty, and epithelial pro- 
liferation not a guarantee, is admitted or at least mooted. 
So it may be as Billroth says : "Ina hundred years will they 
laugh at our present anatomical and clinical definitions of 
cancer." 

While we are dealing with the histological and pathologi- 
cal structures of the tumor, a rapid mortality follows in the 
wake of the disease. The Registrar- General's reports show 
that in England, between the years 1861 and 1871, there was 
one death from cancer in every 2,570. Should it be desired by 
any of my readers to investigate the subject of cancer in rela- 
tion to its histology and pathology, I would respectfully refer 
them to Chapter XIV in Cripps's excellent book on Diseases 
of the Rectum and Anus. It has been taught for so long 
that cancer is transmitted by inheritance that the profession 
accepts the statement without much inclination to disbe- 
lieve it. Cripps, in dealing with this phase of the subject, 
says: "The hereditary nature of cancer is based upon evi- 
dence derived from the following sources : 

"1. That it is a matter of common notoriety that cancer 
runs in certain families. 

"2. Evidence founded upon certain statistical facts." 

I have never had it settled to my own satisfaction that 
cancer was strictly a hereditary disease. The same notion 
obtained in the profession throughout the world in regard 
to phthisis pulmonalis, until Koch discovered the tubercle 
bacillus and revolutionized our idea concerning the disease. 
May it not be that the time will come when something incon- 
trovertible will convince us that our views in regard to the 



368 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

heredity of cancer are also a mistake? "That it is a matter 
of common notoriety that cancer runs in families " can not be 
gainsaid so far as the notoriety is concerned, and yet we all 
know that they are exceptional cases. Sometimes we will 
have a case such as the one narrated by Sir James Paget, "in 
which a lady died of cancer, two of her daughters died of 
cancer, and eight of her grandchildren," and yet, as Cripps 
aptly says, the number of her children and grandchildren 
who did not die of cancer is not mentioned. Now, is it not a 
fact that, where we can recall two persons in the same family 
dying of cancer, we can recall many, very many, cases where 
in large families only one person died of the disease ? I have 
been able, in my practice at least, to do this. The second 
source from which Cripps forms his conclusion is " evidence 
founded upon certain statistical facts." Now, these statis- 
tical facts are usually gathered from the patients themselves, 
and how unreliable such evidence is can be appreciated by 
every physician. Not one in a thousand such people can 
give you a clear evidence that the death in the family to 
which they refer did take place from cancer. It is a fact 
that, before gynaecology had advanced to the scientific posi- 
tion that it now maintains, a great number of deaths occur- 
ring from simple tumors within the abdomen were put down 
in the list as caused by cancer. Further than this, we have 
intimated that the medical testimony is very much wanting, 
because of the difficulty of making out or diagnosticating 
malignant disease. The two most important questions that 
force themselves upon our attention when dealing with sus- 
picious growths are: 1. Is it a malignant or non-malignant 
tumor ? 2. Is its removal advisable ? 

To tell persons who come to you for honest advice that 
they suffer from cancer when there is a reasonable doubt, is 
little less than criminal ; and yet there are circumstances that 
might demand a positive opinion, if such was held. I am in 
the habit of not telling my patients of the existence of cancer. 
By such information I am satisfied that life is shortened. 
Thus we see that a diagnosis becomes of the greatest im- 



CANCER OF THE RECTUM. 369 

portance. I remember upon one occasion I violated this rule 
of mine in the following case : 

Case. — A lady was brought to me suffering from a growth 
in the rectum, and she was accompanied by her physician 
and most of her family. I made a careful examination of 
her case, and, after submitting a specimen of the tumor to a 
microscopist, she said to me: " Doctor, I know that I have 
cancer of the rectum, and I want you to tell me what your 
honest opinion is. I am not afraid to die, and I have some 
important business to arrange looking to such an event which 
will take me some time to accomplish, and it is for this 
reason more especially that I want to know your opinion." 
The doctor confirmed this statement of hers, so I thought 
under the circumstances I would tell her. When I told her 
that I believed she was suffering from an incurable disease 
which might end her life soon, she grew suddenly pale and 
sank back on the bed in a fainting condition. Although 
she supposed she could stand the shock, she overestimated 
her power. For a number of days she was in a serious con- 
dition from the mental impression made on her by simply 
confirming her own idea of her case. The best part of the 
story is, however, the tumor was excised, and it proved to 
be not cancer but benign, and she made a good recovery. 
The consolation that I had was that the microscopical exami- 
nation agreed with my diagnosis in the case. But the case 
illustrates how chary we should be in telling patients that 
they have malignant disease. 

The first question is, Is it a malignant or non-malignant 
tumor ? This is of the most importance to the patient. How 
are we, then, to arrive at a correct conclusion ? 

Diagnosis.— It is not my purpose in this chapter to deal 
with the aetiology of the disease, nor to refer particularly to 
its histological aspect. First, then, I would say, in making a 
diagnosis of cancer, I seldom rely on the microscope. In my 
opinion, the clinical features of a case are of the most impor- 
tance. My remarks apply to cancer wherever located, since 
the characteristics of the disease are the same without regard 

24 



3Y0 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

to locality. Without stopping to argue the mooted points, I 
will state a few observations that I believe to be facts. I am 
inclined to believe that cancer is a local disease, due to trau- 
matism and irritation. I can not substantiate this belief, 
neither can those holding opposite views prove that I am 
wrong. It reminds me very much of a controversy that every 
once in a while goes the rounds of the medical press — viz., 
whether the mother's mark is due to maternal impressions or 
not. Just as soon as it is agitated, there are many cases 
reported that would look to be incontrovertible, and yet, from 
a scientific standpoint, it must be said that the position is 
not tenable. In cases of cancer I have ceased to question 
about family history, and am inclined to take the statement 
of heredity as a coincidence. In other words, in my opinion, 
more escape cancer where family history of the disease ex- 
ists than have it, under the same circumstances. The so-called 
cachexia of cancer is misleading. In advanced stages of the 
disease I have often anticipated but not recognized it. The 
same appearance may be observed under many conditions. 
The same pallor, emaciation, etc., arise from other diseases. 
I do not believe either in any facial indication of cancer. In 
my opinion, if it exists, it is due to fear rather than to infec- 
tion. The man under sentence of death is likely to have it. 
Neither do I believe, with Allingham and others, that the 
odor of cancer is pathognomonic. The authors are accustomed 
to give haemorrhage, or a disposition to bleed, as one of the 
symptoms of cancer. It is not at all characteristic. I have had 
under my observation many cases of cancer which never lost 
enough blood to call it a factor in the disease. Pain is pro- 
nounced a prominent symptom. Even its character is said 
to be peculiar. My record book will show a number of cases 
that have died with the disease, and pain never existed to 
any degree. Age is said to play its part as well. Indeed, I 
have heard some physicians exclude the thought of cancer 
because " the patient was too young." In my practice I have 
met with two cases of cancer in patients under nineteen years 
of age, and in one under seventeen. The majority of cases 



CANCER OF THE RECTUM, 371 

of cancer of the rectum observed by me have been under the 
age of forty-five. Touch is said to indicate much in determin- 
ing the diagnosis. Allingham says: "There is something 
peculiar about the feel of cancer which the practiced finger 
rarely mistakes even for simple indurated ulceration." I 
have often felt for that peculiar gritty feel, and found it in 
but few patients. Hence I am inclined to believe that one or 
more of the so-called symptoms of cancer may be absent. 
If, then, the microscope is not infallible, and many of the 
physical signs are absent, how are we to determine the ques- 
tion? I shall only speak of making a diagnosis when the 
disease is located in the rectum, and deal with the distinc- 
tion between malignancy and non-malignancy, not caring to 
enter into a discussion of the different classifications of can- 
cer. I recognize the fact that certain conditions are malig- 
nant which are not cancerous, yet I deem it quite sufficient, 
for the purpose of elucidation, to speak here only of these 
two types. To attempt anything further than this would 
bring us into the consideration of many knotty questions. We 
have attempted to show that it is a difficult thing to be cer- 
tain in a diagnosis of cancer, and I am equally sure that the 
uncertainty is just as great when we attempt to designate 
the time that a benign tumor has become malignant. After 
a learned dissertation upon the histological aspects and mi- 
croscopical evidences of cancer, Billroth says: "I acknowl- 
edge that it is difficult to distinguish carcinoma from adeno- 
sarcoma and alveolar sarcoma." Therefore, to sum up in the 
matter of making a diagnosis, I would say that the symp- 
toms to be relied on most are (a) a disposition to ulcerate, 
(b) rapid infiltration, (c) secondary deposits. Certainly these 
are more trustworthy than many of the so-called symptoms, 
or often of the revelations of the microscope. No surgeon 
should be guilty of making a positive diagnosis of cancer, 
with or without the microscope, until he has learned the clini- 
cal facts of the case. 

Method of diagnosticating Cancer of the Rectum. — Nothing should 
be taken for granted in examining a patient for rectal dis- 



372 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ease. I have known cancer of the rectum treated for piles, 
and vice versa. The history of the disease, with symptoms, 
should be related by the patient, and not by a second party. 
If cancer be present, some or all of the following symptoms 
will be mentioned : Pain in the back and thighs, general 
lassitude, morning diarrhoea, flatulency, straining at stool, the 
passage of some blood, mucus, or pus. All these may arise, 
it is true, from simple ulceration of the gut, but they are, to 
say the least, suspicious. An examination of the rectum 
should now be made. The best position for the patient is 
upon the left side. An inspection of the external parts may 
reveal much or nothing. It is frequently stated that cancer 
generally begins at the anus. This is not my experience. 
Out of an observation of between one and two hundred cases, 
the majority of them have begun above the anus. Should 
this be the part attacked, however, an external observation 
will reveal the fact. If not, there will be but little evidence 
shown on the outside of the rectum. I have had many cases 
come to me for examination of some supposed trivial rectal 
trouble, and it was revealed that the rectum was filled with 
a cancerous growth. After thorough inspection of the exter- 
nal parts, the rectum proper should be examined. This 
should never be neglected. I have known patients to be op- 
erated on for fistula in ano, the surgeon neglecting to exam- 
ine the rectum, where a cancer existed. Upon more than one 
occasion I have seen patients who had had their piles (?) 
operated on by tying or injecting a portion of a cancerous 
mass. In this disease especially, the best method of exam- 
ining the rectum is with the finger. It should supersede all 
instruments. I have long since discarded the speculum, ex- 
cept in the fewest of cases. There are but two conditions, to 
my mind, with which cancer in the rectum could be con- 
founded — one, simple ulceration with inflammatory deposits ; 
the other, syphilitic ulceration, with or without the conse- 
quent stricture. Mistakes have often been made. I have 
made them. First, from simple ulceration with inflammatory 
deposits. Simple ulcerations can usually be traced to some 



CANCER OF THE RECTUM. 373 

definite cause, as dysentery, foreign bodies, etc. To the 
touch the induration has a smooth, continuous feel. The ul- 
ceration is more or less clear-cut, and the discharge is like 
that in the same kind of ulceration elsewhere. If cancer, a 
firm growth will be felt, involving perhaps only the mucous 
membrane at first, and freely movable, likely epithelial in char- 
acter. If scirrhus, hard nodules are found around, imbedded 
in the submucous tissues, and, in the man, often involving 
the prostate gland. Secondary deposits have likely taken 
place in the glands, liver, etc. If simple ulceration, there is 
no disposition to infiltrate, or for the growth to break down. 
If cancer, the tissue yields to pressure, and infiltration takes 
place rapidly. Haemorrhage from either condition is hardly 
a factor, as neither in my experience bleed much,. except in 
rare instances occasioned by the uncovering of an artery, by 
degeneration of its coats in cancer. The odor, as I have said, 
may be absent in cancer, and is not, therefore, pathogno- 
monic. Some confusion might arise over gland involvement. 
It is true that simple inflammatory action in the rectum may 
excite the same condition in the adjoining glands that is ex- 
cited in the axilla from mammary irritation, or in the groin 
from rectal inflammation. The question would naturally 
arise, Is an inflamed gland already infected ? I could scarcely 
admit this as a principle, and yet no one can definitely say 
just when lymphatic infection takes place. Second, from 
syphilitic deposit, with consequent stricture. When ulcera- 
tion is found in the rectum, it is well to suspect syphilis as 
the cause. I make this rule to apply to all stations in life. 
The rich and the virtuous may be the victims as well as the 
poor and degraded. In an article read before the Kentucky 
State Medical Society I maintained that syphilis was the 
most frequent cause of stricture of the rectum, and not can- 
cer, as stated by some. I am equally sure that many cases 
of syphilitic ulceration of the rectum are mistaken for can- 
cer. Anticipating syphilis in these cases, we should trace 
the history, and carefully examine the throat, skin, scalp, 
shins, etc. 



374 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

Case. — Dr. B. asked me to see a young married woman 
with him who was suffering from stricture of the rectum. 
The doctor was inclined to believe that the condition was 
caused by pregnancy, the patient having borne a child about 
a year before. Upon examination, a stricture was found, be- 
ginning one inch above the sphincter muscle. It was impos- 
sible to introduce the smallest linger through it. A free di- 
vision was made through the constricted surfaces. After this 
her general health improved and she took on flesh. During 
one of her visits to my office she remarked that she had 
failed to call my attention to an eruption that had been on 
her body for some time. I looked at it and suspected syphi- 
lis, but referred her to a dermatologist, who pronounced it 
some skin trouble and prescribed an ointment. She used this 
for a long time without effect. I then put her on fifteen-grain 
doses of iodide of potassium, and at the end of three weeks the 
eruption had disappeared. Arguing from cause and effect, I 
concluded that this woman had syphilis and tha't this dis- 
ease was the cause of the stricture. I am certain that the 
woman was virtuous. There is a wide difference given to the 
feel between cancerous stricture and syphilitic stricture. 
The induration from syphilis is firm but not nodular, and 
does not yield to pressure. There is no rapid infiltration of 
tissue, and contiguous parts are but slowly invaded. The 
discharge from syphilitic ulceration is more like that from 
simple ulceration, and not the degenerated tissue discharge 
of cancer. The stricture from syphilis is like fibrous mate- 
rial—very firm— while from cancer the bands are nodular, 
with a disposition to degenerate. Hence I imagine that the 
diagnosis between syphilitic ulceration of the rectum and 
cancer can be easily made. 

Classification. — A very good division of cancer, at least for 
general utility, would be hard and soft ; and yet the struct- 
ure and clinical characteristics of carcinomas have suggested 
their division into the following varieties : (a) Scirrhus, or 
chronic carcinoma, (b) Encephaloid, or acute carcinoma, (c) 
Squamous epithelioma, (d) Columnar-cell epithelioma. 



CANCER OF THE RECTUM. 375 

I scarcely believe the term colloid should be applied to 
these tumors, from the fact that any of the forms of cancer 
may degenerate into this colloid condition ; nor do I believe 
it would accomplish any purpose to use the word sarcoma to 
differentiate between malignant and non-malignant growths. 
That there are tumors which have connective tissue for their 
type there is no doubt, and I suppose the word sarcoma, 
although meaning very little, is about as good a word as can 
be used. But as we are dealing with malignant tumors, or, 
to speak more properly, with cancerous tumors of the rectum, 
we shall not refer to the word sarcoma. I recognize the fact 
that the intimacy of resemblance between a sarcomatous 
tumor and cancer is so close that the microscope will often 
fail to decide, and I believe that it would be impossible to 
distinguish between them without a reference to the clinical 
facts in the case. Nor do I believe that the distinction is of 
much surgical importance ; for, if a tumor exists in any re- 
gion of the body, rectum or elsewhere, it is the surgeon's 
duty to remove it. He can settle the histological aspect, if 
he so desires, for his own satisfaction after, rather than be- 
fore, the operation. Nor do I consider it essential for treat- 
ment to determine whether a growth in the rectum is a scir- 
rhus one or an epithelioma ; whether it be one or the other, 
the treatment should be radical and not palliative. It is true 
that epithelioma is less malignant than scirrhus, and yet this 
point has very little to do with determining an operation. 
We know that either variety will infect neighboring lym- 
phatic glands and cause a rapid infiltration of tissue and a 
subsequent disintegration. It may be true that epithelioma 
much less rarely reproduces itself in the viscera than the other 
form, though it ulcerates earlier ; but it has the infiltrating 
quality, and the adjacent tissue is made to succumb to its 
ravages. It is only a question of time when an epithelioma 
becomes just as malignant as an encephaloid cancer, which is 
considered as having the greatest degree of malignancy ; 
therefore the histological aspect of cancers aside, I shall refer 
only to hard cancer or scirrhus, which is of the glandular 



376 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

type, and to epithelioma, which is of the epithelial type. It 
is said by most writers that the variety of cancer oftenest 
found in the rectum is of the epithelial type. Now, if we are 
to take clinical evidence as facts, my record book will show 
that the scirrhus form of cancer has been found just as often 
in the rectum as epithelioma ; especially so if we are to be- 
lieve that it takes its origin at the anus and not within the 
rectum proper, and that it begins as a "hard, dry, warty 
nodule." I must confess that I have seen very few cancers 
around the rectum of this nature. Believing in the pathology 
of cancer as I do, if epitheliomas appear at the verge of the 
anus in this manner, I would have the utmost confidence in the 
cure of the patient, if the growth was removed before there 
was any further infiltration or gland involvement. I have 
said that I have often met with scirrhus. I must qualify the 
expression by saying that I believed it to be scirrhus because 
I found it a hard growth and imbedded in the submucous 
tissues. The epithelial form of cancer is supposed to begin in 
the mucous membrane and, for a while at least, is movable 
with it, the difference being that in the epithelial variety you 
could freely move the tumor over the submucous tissues, and 
in the scirrhus form you could freely move the mucous mem- 
brane over the tumor in its incipiency. But whether it be 
one variety or the other, the progress is very much the same. 
True, one may go a little slower in the race than the other, 
but it will have the same disastrous result after a while. It is 
a well-recognized fact that cancer sometimes follows an injury 
and is known as traumatic malignancy. The form of the in- 
jury is said to be a contusion, and a very small affair at that. 
I think this is a very strong point in favor of the local origin of 
cancer, but I do not propose to argue it here, but what I wish 
to say is, that in cancer of either one of the four varieties that 
I have named, or of the six or seven varieties that are named 
by other authors, I wish to impress the fact that it begins at 
one certain local spot, and that the constitutional symptoms 
gradually develop afterward, and while these constitutional 
symptoms are progressing, it is in direct ratio to the infec- 



CANCER OF THE RECTUM. 377 

tion which takes place from the local diseased spot. It has 
been the history of cancer from time immemorial that all of 
our so-called palliative treatment availed but little, if any- 
thing. Indeed, I am persuaded that in many instances, if the 
surgeon had cut away this growth instead of taking time to 
watch the changes from a histological standpoint and wasting 
time about the character and disposition of the cell growth, 
he might have saved life that the disease afterward destroyed. 
Therefore I wish to impress, that in every single case where 
there is a chance of removing the entire growth — and this 
time is more especially during its incipiency — it should be 
done and no time wasted with palliative treatment. It is 
common with authors to say that there are two modes of 
treatment for cancer — viz., palliative and radical. Now, I 
would reverse this order of treatment and say, first radical, 
and afterward palliative. A great deal of time is taken up 
by authors in describing the manner in which cancer spreads 
and propagates itself. This is all very good for the benefit of 
science, but it does no good to the patient. All that is neces- 
sary to know, after making the diagnosis of cancer, is that it 
does spread and propagate itself, and that generally in a 
rapid way. Apprehending this, we should endeavor to inter- 
cept it and end its ravages, if possible. One objection that I 
would prefer against palliative treatment is that it is conceded 
that certain local applications excite malignant growths and 
cause their more rapid extension. There is a common belief 
that by performing an operation for cancer the death of the 
patient is hastened, and the experience of the surgeon en- 
forces the same belief on him. It can not be gainsaid that 
there are many unnecessary operations performed for cancer. 
When the disease has progressed to a certain extent, it is out 
of the question to do any operation, and yet it is done every 
day. I have seen a woman's breast removed for a malignant 
growth and the infected glands in the axilla allowed to re- 
main. I have seen a cancer of the rectum removed when the 
lymphatics in the lumbar and inguinal regions were thorough- 
ly infected and remained untouched. I have seen a hysterec- 



378 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

tomy done when the woman was already dying of sepsis. 
Better not do any operation at all than a half-way one or to 
operate when it will do no good. 

Symptoms. — I have referred already in an incidental way to 
the symptoms in rectal cancer, but I wish to add that they 
are so few and impronounced as to have very little weight in 
the incipiency of the growth or to call our attention to it. 
Indeed, there are no symptoms at all in the very beginning 
of the rectal cancer other than those set up by irritation and 
reflected to contiguous parts. One person may complain of 
vesical irritation, another of pain in the back. As the disease 
advances these patients are frequently prescribed for as having 
diarrhoea or dysentery. A scirrhus cancer, originating as it 
does in the submucous tissues, does not involve the mucous 
membrane for quite a while ; therefore the ulcerative process 
is very slow to take place, and we have no blood and mucous 
discharge until the tumor is very pronounced and its mucous 
covering has become ulcerated. Unfortunately, it is too true 
that the nature of this disease has escaped the notice of the phy- 
sician, and the surgeon sees the case after it is fully developed, 
when in the majority of instances it is too late to operate. 

Case I. — I was called to see a lady in the southern part 
of the city who had been so constipated (?) for a number of 
weeks that her bowels had refused to act even in response to 
a strong purgative treatment. This woman had no special 
cachexia and was in her usual flesh, with good appetite, loco- 
motion good, and she was in the habit of attending to her 
regular duties and visiting her friends. I had her family 
physician called, when I made an examination, and found a 
hard cancer beginning above the sphincter about two inches 
and nearly completely blocking the rectum. She had never 
had any special diarrhoea and no discharge of blood or mu- 
cus, and yet the case was a very plain one. At this stage of 
the disease I did not advise any special treatment except to 
keep the bowels open, which was accomplished at first by the 
introduction of a very small rectal tube and injecting above 
the growth. This case took the usual course. 



CANCER OF THE RECTUM. 379 

Case II. — A lady was sent to me a short while ago from 
the extreme South with a letter from her doctor, who said to 
me that he had detected a growth in the rectum, but could 
not determine its nature, and therefore had sent her to me. 
This woman weighed at least one hundred and fifty pounds, 
was of a very good color, ate and digested her meals, and did 
not regard herself as an invalid. An examination revealed 
the existence of a hard cancer on the dorsal aspect of the rec- 
tum, fully the size of my fist, with infiltrations above. She 
being a long way from home and alone, I thought it my duty 
to tell her that she was in a serious condition, but did not 
reveal to her the nature of her trouble. I advised her to 
return home, and when the obstruction became more pro- 
nounced to return to Louisville, when I would do a colotomy 
upon her. I explained to her the nature of this operation, as 
I do to all patients that I expect to do a colotomy on. She 
went South, and her doctor wrote me that she began to de- 
cline rapidly from that time, and he believed that much of it 
was due to her mental depression, she having conceived the 
idea that she had cancer, or, in any event, she dreaded the 
operation proposed. In his second or third letter, which was 
about three months from that time, he wrote me that she 
had died. 

Case III. — I was called to see a wealthy contractor who 
had total obstruction of his bowels. This man weighed two 
hundred and twenty pounds, and had never complained of 
any rectal trouble ; indeed, had complained of no trouble at 
all except the difficulty in having an action within the last 
two or three weeks. Up to this time he had been able to 
attend to all his arduous duties simply because he regarded 
himself as a well man, not knowing that he had any disease. 
A rigid examination showed a cancer in the sigmoid flexure, 
and a total obstruction at its entrance. 

These cases illustrate the fact that the course of the dis- 
ease is very insidious. They also demonstrate that the well- 
recognized symptoms observed ordinarily in cancer of the 
rectum may be absent. Those who contend that cancer is a 



380 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

constitutional disease, with local manifestations, might with 
a good deal of force in their argument say that malignant 
trouble frequently existed in the rectum where trauma could 
play but little part. When speaking of traumatism it should 
not be supposed that it is necessary to find a wound of any 
extent or dimensions. A lesion scarcely perceptible to the 
naked eye is quite sufficient to admit of the micro-organism 
which produces tetanus, and a lesion in the rectum of the 
same insignificance may be the starting-point of cancer. We 
have said that a local irritation of malignant growths will 
excite them to further development. We can also add that 
local irritation may excite a cancer, thereby being its cause. 
It is proverbial of the chimney-sweep that he is a special sub- 
ject for cancer, and yet I imagine that no one would take the 
position that cancerous patients were habitually chimney- 
sweeps. It must, therefore, be due to the local irritation that 
the malignant abrasion was started, and that it increased by 
said irritation being kept up. The belief common is that a 
point of whalebone will set up an irritation which may end in 
malignancy ; and it has become a common practice with phy- 
sicians, whether they believe it or not, to try and trace the 
tumor in the woman's breast to the pressure of her corset. I 
dare say that there are but few surgeons but can trace cancer 
in some of their patients to a blow or a fall, or to some sort of 
irritation at a local spot, and how often it is that in cancerous 
growths embracing the periosteum the disease can be traced 
to some injury done to it by a lick or a kick or trauma of 
some kind ! It is also a recognized principle in surgery that 
growths of any kind involving the tissues should not be sub- 
jected to a continual local irritation. Therefore, apropos to 
this line of thought, the anatomy of the intestines, taken 
along with the physiology of defecation, proves the fact that 
there are three points of retention and accumulation of the 
faecal mass — viz., the caecum, the sigmoid flexure, and the rec- 
tum. The csecum is the starting-point of this mass, from 
which it is hurried along to the sigmoid flexure, and then 
dropped into the rectum. If this is not passed, antiperistaltic 



CANCER OF THE RECTUM. 381 

movement lifts the mass back, or much of it at least, into the 
sigmoid, and there it remains for a time in its dried condition. 
Now, it can be easily understood that all of the mass, perhaps, 
does not start on its onward course from the caecum ; some of 
it remaining becomes dried and acts as a local irritant. Then 
the sigmoid, becoming the receptacle of the mass when refused 
by the rectum, and the rectum holding a portion of the mass 
each day, both are irritated thereby. The natural pathology 
would be that a congestion of the blood-vessels was started at 
one of these points, which was followed by an abrasion and 
inflammation. The fight still wages with pathologists whether 
it is the appendix vermiformis or the caecum which is respon- 
sible for the degree of inflammation and consequent suppura- 
tion, which is so often followed by death ; and yet I imagine 
that there is no one so enthusiastic in his advocacy of the 
appendix being responsible for this condition that would 
not admit that the caecum frequently becomes impacted with 
faeces, which results disastrously. It will be admitted that the 
three points named — the rectum, the sigmoid flexure, and the 
caecum — are favorite seats for cancer. We have shown how it 
is possible that an abrasion may be made by these hardened 
faeces, and a continual irritation kept up by their presence. 
Therefore I am not willing to admit that cancer can not be 
caused in the rectum by trauma as well as in any other part 
of the body. That mechanical irritation, either from pressure 
continued or from a constant rubbing of the part, will pro- 
duce cell-growth, can not be denied. We have many exam- 
ples of it in small benign tumors which grow in this manner. 
We are all suspicious of warts, and advise the patient not to 
subject them to a continuous friction. If they are so sub- 
jected, we see the evidence of it in rapid cell-growth. The 
natural follicles of the gut may be by such friction the start- 
ing-point of cancer. It is frequently urged, to rebut such 
evidence as this, that secondary deposits take place from can- 
cer in the different organs of the body. I can not think that 
this disproves the local origin of cancer any more than to say 
that we find tubercular disease in the rectum in the man who 



382 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

has a tubercular deposit in his lungs. The lymphatic system 
is very wonderful, and may be responsible for the migration 
of the micro-organisms, cells, or what not which produce the 
disease. Whatever may be the solution to these knotty prob- 
lems, the thing of the most moment to us in dealing with 
growths about the rectum is to distinguish between the ma- 
lignant one and the one that is not malignant. When this 
problem is solved we can consider the treatment. 



CHAPTER XVII. 

TREATMENT OF CANCER OF THE RECTUM. 

There are but three methods to be considered in the treat- 
ment of cancer of the rectnm : 1. Colotomy. 2. Extirpation. 
3. Palliative treatment. 

Colotomy. — In delivering the Bradshawe lecture before the 
Royal College of Surgeons, London, Mr. Thomas Bryant se- 
lected as his subject Colotomy. He said : "But, as a means 
of giving relief to patients with chronic intestinal organic 
ulcerations or obstruction from whatever cause, colotomy was 
generally, and indeed I may say is still, too much regarded 
as a dernier ressort, and as a consequence it was, as a rule, 
only carried out wdien all other measures had been tried and 
proved to be useless. This position I, in common with some 
few other surgeons, have, however, never accepted. We have 
regarded it as the best means the surgeon has at his dispo- 
sition for the relief of rectal obstruction from cancers, and 
every disease which is not otherwise removable, and expe- 
rience has proved that life may by it be saved when the dis- 
ease is not cancerous, and prolonged even for years when it 
is so." 

Turning to page 605 in Wyeth's excellent text-book on 
surgery, we read : "In stricture of the rectum, when all other 
measures fail, colotomy is the last resort." 

Here are diverse views by two very distinguished authors. 
Which is correct ? I am decidedly inclined to Dr. Wyeth's 
opinion (if colotomy is performed at all), and, although he has 
been content with the bare statement without argument, I 
shall in a few words give my reasons for differing from Mr. 
Bryant in his statement and proposition. I quite agree with 



384 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

him in the preference given to lumbar over inguinal colotomy 
in cases of cancer of the rectum, and especially in cancer of the 
sigmoid flexure -; but I beg to differ as to the need of the oper- 
ation, and I base my belief on the clinical facts as evidenced 
by the disease. Instead of admitting his premise that colotomy 
is called for in the relief of rectal ulceration, the result of 
cancer and other diseases, and should be performed early in 
the disease, I shall contend that such a procedure is warranted 
only in the rarest cases, and then as a dernier ressort only, 
which he denies. My conclusions are based upon an obser- 
vation of several hundred cases of so-called obstruction of the 
rectum. I shall not found my objections upon the dangers 
that attend the operation, although every surgeon will admit 
that some danger attends it. I recognize the fact that under 
antiseptic surgery the mortality attending these, as well as 
all other surgical operations, is reduced. However, this ad- 
mission plays no part in rebutting other arguments that are 
urged for the operation. I will be permitted to remark that, 
in my opinion, it has become too much the custom, or fad, to 
do this operation in cases where there is no possible chance 
of doing the patient any good. Indeed, it has become so 
common with some surgeons, that the moment cancer of the 
rectum is diagnosticated colotomy is done. Mr. Bryant states 
two distinct propositions — viz. : u l. The immediate success 
or failure of the operation turns but little upon the operation 
itself if well performed, but upon two main points, the first 
being the local condition of the bowel above the seat of ob- 
struction, and the second on the general condition and age 
of the patient." 

Some surgeon once said that the reason laparotomies for 
gunshot wounds showed such a low per cent of recoveries 
was, that too many were attempting the operation. Mr. Bry- 
ant can very well say that the immediate success or failure of 
colotomy turns but little upon the operation if it is well per- 
formed. The trouble is that, if his premise be true, this 
operation should not be considered as a last resort in cancer, 
but that it should be resorted to early in the disease, and is 



TREATMENT OF CANCER OF THE RECTUM. 385 

the best of all procedures ; too many men, accepting his dic- 
tum as true, will be doing the operation when less dangerous 
methods might accomplish the same results. As to his two 
main points to be considered before doing the operation : 
First, "the local condition of the bowel above the seat of 
obstruction." I take it that he means whether the bowel 
above the seat of obstruction is invaded by the disease, or if, 
in consequence of the disease below the seat of obstruction, 
the function of the bowel has suffered. In my opinion, it 
would have been more to the point to have considered the 
local condition of the bowel both above and below the seat 
of obstruction. He says: "If from procrastination serious 
intestinal changes have taken place before relief is present, 
recovery is hardly to be expected." I suppose, of course, 
that the distinguished author refers here to cancer, and not to 
non-malignant growths, as the ' ' serious " cause of intestinal 
changes. Suppose the gut above the stricture was not in- 
vaded or changed at all, but that below the stricture there 
was a slight infiltration by cancerous deposit, is the operation 
justifiable % I certainly can not agree that it is. Admitting 
that there was considerable infiltration and a growth of some 
size, even then I could not admit that it was justifiable. No 
one can deny but that a colotomy is a loathsome and disgust- 
ing thing. Patients with cancer of the rectum live from three 
to six years. Many in my practice have lived five years after 
the disease was first observed, and in comparative comfort. 
Why subject these people to such an operation during the 
incipiency of the disease when it does not stop it % Again, 
are we quite certain that there is an infallible sign of cancer % 
I have already spoken of the great difficulty in deciding this 
question by the microscope, and even by the clinical history 
of the case. From quite a number of patients I have taken 
specimens from rectal growths, had them examined by a mi- 
croscopist and pronounced cancer, whose subsequent history 
revealed the fact that it was not cancer at all. In a preceding 
chapter in this book I have so stated, and given a history of 
several cases. Then, too, in the early stages of cancer there 

25 



386 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

is not sufficient clinical evidence to base an opinion upon. 
Certainly for a benign stricture, growth, or obstruction in 
this locality, colotomy would not be advised unless it was 
impossible to remove the growth, and it was producing great 
obstruction. Again, if the disease be cancerous, whether 
it be incipient or confirmed, can the operation of colotomy 
cure it ? It might be, as Mr. Bryant suggests, that the opera- 
tion could be done much more successfully while the general 
health is in good condition, but it is not whether one can 
perform colotomy successfully or not, or whether the patient 
can stand the operation well or indifferently. The prime 
question should be, What good will it do \ A surgeon may 
do a beautiful operation for stone in the bladder and get the 
stone, but the patient dies ; or a woman may bear the oper- 
ation for the removal of her womb when she is constitution- 
ally affected by sepsis. In all candor I would ask, Can the 
establishment of an artificial anus in the side in any way 
arrest or cure a cancer in the rectum % If it is granted that 
the disease has already become a constitutional one by in- 
fection, regardless of the opening in the side, I would ask, 
Can the colotomy prolong the life of said individual ? In no 
possible way can it do so, even to the minds of those who 
advocate the operation, but one, viz., by preventing one 
source of irritation— the passage of faeces over the cancerous 
mass— the argument being, the more irritation the more de- 
posit. In my opinion, this proposition is of very little impor- 
tance or consideration in dealing with cancer of the rectum. 
The increase of the growth that would occur by the local irri- 
tation excited by the passage of the faeces over it would, to 
my mind, be of very little moment to the patient ; and, as a 
fact, malignant growths increase by an inherent power, depo- 
sition, infiltration, etc., more intrinsic than extrinsic. These 
growths will exist in the rectum a long time, acquiring a 
great size, involving, perhaps, the whole circumference of the 
gut before the mucous membrane is ulcerated, and frequently 
before any special pain is excited. Whereas I believe that 
local irritation has more or less to do with the increase of a 



TREATMENT OF CANCER OF THE RECTUM. 387 

cancerous mass that is subjected to its influence, I have never 
seen much difference in cancers of the rectum, so far as rapid 
progress is made, before or after colotomy was done. As I 
have before stated, my patients have generally lived from 
four to six years without colotomy. Do they live any longer 
with colotomy % These patients die generally of sepsis, and 
the mass is left from which the infection takes place. In 
other words, can one say because colotomy has been per- 
formed, and the patient lives from four to six years, that 
colotomy was the cause of prolonging life 1 Again, it is 
claimed that by colotomy much of the pain in the rectum 
is relieved, because the faeces have been directed from their 
natural course. In some instances this may be true, but the 
rule will not hold good in all. I have known patients to 
suffer equally as much with pain after as before the oper- 
ation. Nor is it always true that the faeces are diverted from 
their natural channel. In some cases, perhaps the fault of 
the operator, patients complain of discomfort from the faeces 
lodging along the route, or at least complain as much as 
they did before the operation was done. In a paper read 
by Mr. Jessop on the Treatment of Cancer of the Rectum, 
at the Leeds meeting of the British Medical Association, he 
said: "In cancer of the rectum the constriction in the ma- 
jority of cases can be got over for a time by injections, the 
introduction of the linger or bougie, the use of laxatives, and 
the like." This has certainly been my observation. Indeed, 
I have seen many cases of cancer of the rectum where the pa- 
tient never complained of constipation or obstruction. Add 
to this that many patients of the kind complain of but little if 
any pain, which is certainly true, especially if the growth is 
situated above the sphincter muscle ; it lessens the cases ma- 
terially which would call for colotomy. I can not agree with 
Mr. Bryant in his statement that the operation is demanded 
for the purpose of relieving the local distress, admitting, as 
he does, that when the disease is in the lower part of the 
rectum, obstruction seldom occurs. At one time I had seven 
cases of cancer of the rectum under observation, and in 



388 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

but one was pain a factor at all. Admitting that pain is a 
prominent symptom, colotomy does not bring that radical 
relief which would justify its being done simply to meet this 
symptom. We have in opium a remedy which will quiet 
pain effectually, and if the argument be used that we would 
make an opium habitue of the patient, I would ask, What is 
the difference if he is to die so soon \ Pain in cancer is inher- 
ent, caused by the local affection or pressure on the nerves, 
and is not controlled by extraneous circumstances ; hence, of 
what account is opening the gut at a distant point if pain is 
not a great factor in the disease, and is not caused by the 
pressure exerted by the faeces % If it is admitted that the 
irritation and pain are caused by the fecal mass — which I 
doubt — if there be a stricture, dilatation would materially 
prevent this pressure. Not long since I saw, in consultation, 
a lady whose lower rectum, including also the buttocks and 
labia, were involved in a cancerous growth, the gut for six 
inches tightly strictured, and when asked how T much pain 
she suffered, replied: "Oh, very little," and said that the 
fecal discharge caused her no pain. If, as some would have 
us believe, colotomy prevents the extension of the disease 
and its consequences, such as an involvement of the bladder, 
vagina, etc., I would ask, How is colotomy to prevent it % It 
is not the passage of fecal matter over the affected part 
that causes this result, but rather the nature of the disease 
to infiltrate and break down the tissue. If a cancerous 
growth is situated above the sphincter muscles, its tendency 
is to extend upward, and in this event pain is not great 
unless some other organs are affected. It is not uncommon 
that patients come to my office to consult me for some trivial 
rectal affection, and I find upon examination a cancerous 
mass extending around the rectum, pain being scarcely a 
symptom. Of what value would colotomy be here % Hence 
I am forced to the conclusion that the operation is not 
warrantable, simply because cancer is found in the rectum, 
whether it be in an incipient or confirmed state ; nor for the 
relief of pain simply, unless other complications exist, be- 



TREATMENT OF CANCER OF THE RECTUM. 389 

cause we have medicine which will relieve pain ; nor to pre- 
vent invasions by the disease, because it would fail of its 
purpose. Infiltration and further pathological change can 
not be overcome by colotomy. Nor do I subscribe to the 
belief that the operation should be done for an existing ob- 
struction or the anticipation of the obstruction in the lower 
rectum, because, as Mr. Jessop says, this obstruction seldom 
takes place, and if it does it can be relieved by dilatation 
and other methods. Nearly a year ago Dujardin-Beaumetz 
called attention to a plan of handling this disorder which, in 
his hands, had given results at least favorably comparable to 
surgical results. 

He regards cancer of the rectum as ordinarily of slow 
growth, and its dangers to be partly the result of the intes- 
tinal obstruction which it produces, partly a poisoning from 
the absorption of the broken-down tissue of the tumor, and, 
lastly, the mechanical results of its pressure on the ureters. 
To limit the action of these factors, intestinal antisepsis is 
at least partially available. By irrigation of the bowel, the 
region of the tumor is kept clean, as well as the sacculated 
portion of the bowel above it. Stercorsemia from retained 
fseces is less liable to occur. For purposes of irrigation, 
Beaumetz uses a solution of naphthol — about four grains to 
the quart. Of intestinal antisepsis to be given by way of the 
mouth, he prefers salol and bismuth. To still further effect 
this object, laxatives are employed for the purpose of moving 
the bowels at least once a day. By the use of a diet of milk, 
eggs, fruit starches, and vegetables, the amount of material 
put into the intestinal canal, and capable of undergoing 
putrefaction and forming poisons, is much diminished. 

Under the above plan of treatment he has found that the 
offensive discharge from the bowels has ceased, and the pa- 
tients have gained in weight and strength. Lastly, I do not 
believe that colotomy should be done for obstruction in the 
rectum by cancer except in a few cases, and then only as a 
dernier ressort. I know that colotomy is advised and prac- 
ticed bv a few for other ulcerations besides those of cancer 



390 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

of the rectum. Except under certain conditions, I would 
object to this procedure as much as to the indiscriminate 
performance of the operation for cancer. 

BlsJc of Life. — I was in consultation a short time ago 
when colotomy was discussed for the relief of the patient, and 
I was surprised to hear one of the surgeons remark that it 
was a very simple operation. Mr. Cripps says : " Colotomy is 
an operation of great delicacy, requiring a good anatomical 
knowledge, with trained manipulative skill." Any surgeon 
in the habit of doing either one of the colotomies will bear me 
out in saying that the operation, especially if complicated, 
is difficult of execution and fraught with danger. In the 
eight years from 1869 to 1877 the number of colotomies which 
were performed at the two hospitals of St. Bartholomew's 
and Guy's amounted to thirty-nine cases with twenty-seven 
deaths, or a mortality of sixty-six per cent. Treves, quoting 
Erckelens's statistics, published in 1884, states that out of one 
hundred and ten cases of colotomy for cancer, forty-two 
died, a mortality of thirty-eight per cent. Of course it is to 
be admitted that in the hands of experienced operators, espe- 
cially when the operation is done under strict antiseptic pre- 
cautions, no such mortality as this would be recorded. Her- 
bert Allingham, Reeves, Bryant, Kelsey, and others have 
reported a considerable number of cases, with a very small 
mortality. But this operation is very much alike in its re- 
sults to that of abdominal section for the removal of the ova- 
ries, tubes, etc. ; it is being done by too many inexperienced 
hands. There can be no doubt that the heavy mortality list 
published by Erckelens was mainly due to badly selected 
cases, inexperienced operators, and the want of antiseptic 
precautions. 

Method of Operating. — The question has been strongly mooted 
by distinguished surgeons as to which of the two colotomies 
is the better : the one done in the lumbar region and known 
as Amussat's operation, or the other, done in the inguinal 
region, and frequently called Littre's operation. Mr. Thomas 
Bryant is a strong advocate of the lumbar operation, and Mr. 



TREATMENT OF CANCER OF THE RECTUM. 391 

H. Allingham and Reeves much prefer the inguinal method. 
The subject has been argued pro and con by these distin- 
guished gentlemen for some time, but neither those on one 
side or the other have given an inch in the controversy. 
The chief grounds upon which the surgeons who prefer the 
inguinal operation base their argument are as follows : 1. 
That the iliac operation is in itself easier than the lumbar. 
2. That by means of the abdominal incision diagnosis in ob- 
scure cases may be verified before the bowel is opened. 3. 
That by it there can be no possibility of the surgeon's mis- 
taking the small intestines, duodenum, or stomach for the 
large intestine, and that abnormalities of the colon do not 
mean failure of the operation, since the abdomen can, by the 
inguinal wound, be carefully searched. 4. That the bowel can 
be readily drawn out of the wound, and consequently firmly 
fixed to the skin, without causing undue tension on the 
stitches. 5. That in lumbar colotomy there is frequently so 
much prolapse of the gut as to give rise to serious trouble. 
6. That the inguinal position of the wound is far more con- 
venient to the patient for cleanliness as well as for the adjust- 
ment of pads to guard against the escape of fseces and flatus. 

Mr. Bryant deals with each one of these claims seriatim, 
and comes to the following conclusions : 

"1. For the iliac operation to be a success, the large bowel 
should not be loaded with faeces, the abdomen be by no means 
tense, and the symptoms of obstruction far from urgent, since 
under opposite conditions (such as those too commonly met 
with) its supposed advantages would hardly be demonstrated. 
The searching for the bowel would, moreover, be a serious 
difficulty ; the free manipulation, extrusion, or excision of the 
bowel which is advised would be unsafe even if practicable, 
and the necessity of having to open the bowel upon its ex- 
posure would, when called for, add to the dangers of the 
measure. The iliac operation, consequently, would appear to 
be applicable to only a small class of cases. If, then, it can 
be said that iliac colotomy is an easier operation than the 
lumbar when the large bowel is empty, the abdomen flaccid, 



392 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and the symptoms of obstruction unpronounced, it can with- 
out hesitation be asserted that, with a distended abdomen and 
colon and urgent symptoms, the lumbar operation is the sim- 
pler of the two. 

"2. To search for the colon in iliac colotomy performed 
upon a patient with an undistended abdomen and free from 
all urgent symptoms may neither be difficult nor dangerous ; 
but with the opposite condition, in which the bowel is dam- 
aged above the immediate seat of disease from prolonged 
obstruction, danger must exist, and such danger must be 
added to that which appertains to the peritoneal wound. In 
lumbar colotomy neither of these dangers has to be met. 
Such searching for extrusion and dragging outward of the 
colon as is considered to be essential in the iliac operation is 
never requisite, since the spur which is considered to be so 
essential to guard against the passage of faeces past the arti- 
ficial opening in the iliac method can in the lumbar be ob- 
tained by far simpler means. 

"3. The prolapse of the bowel at the artificial opening 
which has been adduced as an objection against lumbar co- 
lotomy does not rightly or of necessity belong to it. To judge 
by my own experience, it is imaginary. In the iliac opera- 
tion the objection is admitted, and sought to be remedied by 
an operative measure which is in itself of far greater mag- 
nitude than any lumbar colotomy I have ever done or seen. 

"4. The fear of an abnormity of the colon, rendering the 
operation of lumbar colotomy a failure, is practically ground- 
less. I have known it to occur but once in my own practice, 
and in that case the patient suffered no harm. Such a fear, 
therefore, need in no way tell against the lumbar measure. 

"5. The greater convenience of the iliac over the lumbar 
wound for toilet purposes may, at first sight, seem plausible, 
but this apparent advantage is more than counterbalanced by 
the greater difficulty that exists in keeping any dressing or 
compress in position over the anterior opening, to prevent the 
escape of the intestinal contents, than is ever experienced over 
the lumbar. 



TREATMENT OP CANCER OF THE RECTUM. 393 

u 6. The final conclusion is therefore clear, that iliac colot- 
omy is not yet proved to be superior to the lumbar opera- 
tion. In doubtful cases in which an exploratory incision is 
required for diagnostic purposes it may be useful, but such 
cases are very few. In all others lumbar colotomy has ad- 
vantages which stamp it as the better measure. The single 
advantage that I can see in the adoption of the iliac method 
is that the question of operative interference will have to be 
taken into account at a far earlier period of the patient's 
trouble than it has been hitherto the custom to consider the 
propriety of the lumbar operation ; if so, we may soon see 
the valuable operation of lumbar colotomy take its right 
place in the practice of surgery, and good may come out of 
a fashion which has certainly not been a universal success." 

I am much inclined to believe with Mr. Bryant in the ma- 
jority of his conclusions. I am cognizant of all that is said 
by those who do inguinal colotomy in preference to the lum- 
bar operation in regard to the perfect safety of opening the 
peritoneal cavity under aseptic precautions ; nevertheless, it 
can not be gainsaid that it is more dangerous to open the 
peritonaeum than not to open it, even with these precautions. 
I know, too, that it is strongly asserted, especially by Ailing- 
ham, Jr., that in doing a lumbar operation the peritonaeum is 
often opened. Notwithstanding what he and others have 
said, I believe that I can tell when the peritoneal cavity has 
been opened in doing the lumbar operation, and such a result 
has not occurred in my experience, and in Mr. Bryant's one 
hundred and seventy cases of lumbar colotomy the peritoneal 
cavity was opened but twice. It is urged in favor of the iliac 
operation that there can be no possibility of the surgeon's 
mistaking the small intestines, duodenum, or stomach for the 
large intestine. It would be just as well to say that it is dan- 
gerous to attempt to ligate internal haemorrhoids because of 
the possibility of mistaking the prostate gland for a pile. A 
surgeon who could not distinguish the stomach from the 
colon ought not to attempt a colotomy. Another strong objec- 
tion to the iliac operation is, that if cancer be located in the 



394 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

upper rectum or sigmoid flexure, it may soon embrace the 
opening made in the inguinal region. The lumbar operation 
being done on the colon at a greater distance from the diseased 
part, is not so apt to be embraced by it. I have not the time 
or disposition in this chapter to argue further the pros and 
cons of this much-mooted question, nor can I see that it 
would be of any practical value to my readers. I think 
Mr. Bryant has met all the objections against the lumbar 
operation, and I quite agree with him when he says "iliac 
colotomy is not yet proved to be superior to the lumbar 
operation " ; and while I must agree with those who favor 
Littre's method when they say that it is easier of execution 
under most circumstances, I would suggest that this is no 
argument in its favor. 

Manner of doing the Inguinal Operation. — In doing a colotomy 
it is necessary to observe all the rules of asepsis. Although 
the operation is for the relief of a disease which has a dis- 
charge of pus, etc., and may be considered already septic, 
we are going to deal with a part that is not contaminated, 
and therefore it is necessary to prepare the patient for the 
operation. The evening previous the bowels should be 
moved thoroughly. On the morning of the operation an 
enema of hot water should be given, and the patient advised 
to take a hot bath. Having observed the precaution to do 
without the preceding meal, he is ready for the operation. 
Having a good light, and all preparations concluded, the pa- 
tient is put upon the operating table, the abdomen, inguinal 
region, and surrounding parts are sponged off with ether, 
and, if necessary, the hair is removed with a razor. The sur- 
face of the body surrounding the part is covered with dress- 
ings which have been sterilized. The instruments are in a 
solution of carbolic acid (three per cent), and the operator 
and his attendants thoroughly aseptic. It must not be for- 
gotten that we have to deal with the peritoneum in this 
operation. I like the manner in which the incision is made 
by Cripps, which is a little higher than that made by most 
operators. An imaginary line is taken from the anterior su- 



TREATMENT OP CANCER OF THE RECTUM. 395 

perior spine to the umbilicus ; the incision, two inches and 
a half long, crosses this at nearly right angles and an inch 
and a half from the anterior spine ; consequently, half the 
incision is above and half below the imaginary line, as shown 
in the cut. 



fs 





/• 



Shows the line of incision adopted by Harrison Cripps for inguinal colotomy. An imagi- 
nary line is taken from the anterior superior spine to the umbilicus. The incision, 2i 
inches long, crosses this at nearly right angles at 1£ inch from the anterior spine. 

In making the incision, the skin should be drawn a little 
inward, so as to make the opening somewhat valvular. The 
peritonaeum being reached, it is pinched up by fine forceps 
and an opening made sufficient to admit the finger. The 
intestines being protected by the finger, the peritonaeum is 
divided by scissors to nearly the full length of the cutaneous 
incision. The colon may now at once show itself, and can 



396 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

easily be recognized by its longitudinal bands and by the 
convolutions of its surface. Often the large intestine will 
present ; at other times the small intestine, omentum, or mes- 
entery will first appear. If they do, they should be pushed 
back and the colon sought for. It can often be detected by 
the scybalous masses within it, or it may be traced by the 
finger after passing it into the pelvis, feeling for it as it 
crosses the brim. Some difficulty is sometimes encountered 
by the small intestines protruding, but these should be care- 
fully returned into the abdominal cavity. The colon being 
found, a loop of it is drawn into the wound. In order to 
avoid the prolapse which is likely to occur if loose folds of 
the sigmoid flexure remain immediately above the opening, 
gently draw out as much loose bowel as will readily come, 
passing it in again at the lower angle as it is drawn out 
from above. In this way, after passing through one' s fingers 
an amount varying from one to seven inches, no more will 
come. Two provisional ligatures of stout silk are now passed 
through the longitudinal muscular bands opposite the mesen- 
teric attachment. These provisional ligatures, the ends of 
which are left long, help to steady the bowel during its sub- 
sequent stitching to the skin, and, moreover, are useful as 
guides when the bowel is ultimately opened. They should be 
about two inches apart. The bowel is now temporarily re- 
turned into the cavity. With a pair of fine forceps the parie- 
tal peritonaeum is picked up and attached to the skin on each 
side of the incision, the muscular coats of the abdominal wall 
not being included. Four sutures of fine Chinese silk are 
sufficient — two on each side, an inch and a half apart. The 
bowel is again drawn out and fixed to the skin and parietal 
peritonaeum by seven or eight fine ligatures on each side, the 
last suture at each angle going across from one side to the 
other. The bowel should be attached so as to have two thirds 
of its circumference external to the sutures. By turning the 
bowel slightly over, the lower longitudinal band can be clearly 
seen, and it is best to pass the sutures for the lower side 
through this, since it is a strong portion of the gut. The up- 



TREATMENT OP CANCER OF THE RECTUM. 397 

per longitudinal band, through which the provisional liga- 
tures have already been passed, is seen in the middle line of 
the wound. The bowel being now turned downward, the 
opposite line of sutures are inserted close to its mesenteric 
attachment. No longitudinal band can, however, here be 
seen. The sutures of silk are passed by small, partly curved 
needles, the needles passing through the skin, one eighth of 
an inch from the margin, then through the parietal layer of 
the peritonaeum, and, lastly, partly through the muscular coat 
of the bowel, great care being taken to avoid perforating the 
mucous membrane. It is easier to pass all the threads before 
tying them up. The wound should be most carefully and 
gently cleaned. The threads can then be all tied with mod- 
erate tightness. If the case is urgent, the bowel may now be 
opened ; if not, a piece of green protective is put over it — a 
necessary precaution to prevent the granulations adhering to 
the gauze. The whole is covered with an antiseptic dressing, 
an additional thick pad being placed over the site of the 
wound. A broad flannel bandage is then wound firmly around 
the abdomen so as to insure considerable pressure. 

Different operators have employed different plans in doing 
this operation, and therefore I shall mention several others in 
connection with this, that the special points may be observed. 
Luke commenced the operation by making a perpendicular 
incision in the groin, four inches long and just outside the 
course of the epigastric artery. The sigmoid flexure was 
sought for and pulled into the wound, the gut being opened 
at once. This plan, however, has gone out of use. Reeves 
makes the usual incision in performing the operation — viz., 
one an inch above Poupart's ligament, extending from a point 
just external to the abdominal ring to a little below the ante- 
rior superior spine of the ilium, the incision being between 
three and four inches in length. Sutures are passed through 
the gut to fasten it to the skin. 

As I am very fond of the manner in which Herbert Ailing- 
ham does the inguinal operation, and have taken occasion to 
practice it a number of times, I beg to use his own words in 



398 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

describing his operation : ' ' The manner in which I now per- 
form the operation is by making an incision two inches in 
length, about one inch inside the anterior superior spine of 
the ilium, and parallel with Poupart's ligament. The ab- 
dominal muscles are divided, and bleeding stopped. On 
reaching the peritonaeum, a small incision is made into it and 
the cut edges taken hold of with clip forceps and held up by 
the assistant. Scissors are then used to cut through the 
peritonaeum to the size of the wound. The reason I clip the 
peritonaeum is to prevent its slipping or being pushed away. 
Also, when held up, it stops any oozing of blood from the cut 
muscles passing into the abdomen. A fiat sponge with a 
string attached, to prevent its being lost in the belly, is next 
introduced to keep the intestines out of the way, and to 
catch any blood that might otherwise drain into the abdomen 
while the parietal peritonaeum is being carefully sewed with in- 
terrupted, fine carbolized silk or catgut to the skin all round. 
By joining the skin and peritonaeum in this way, rapid healing 
takes place, and the chances of any discharge fiuding its way 
into the peritoneal cavity are lessened. The sponge being 
removed, a search is then made for the sigmoid flexure. In 
three of the cases it bulged into the wound, and was easily 
recognized by the longitudinal bands and appendices epi- 
ploicce. When the large intestine does not present itself, I 
pass my first finger into the abdomen, sliding it over the 
iliacus muscle until I arrive, at the intestine, which I hook up 
to the opening with my finger and thumb. If this manoeuvre 
fails to find the gut, I search toward the sacrum, feel for the 
rectum, and trace the gut up. Should this not succeed, the 
finger must be passed upward toward the kidney, and the 
descending colon felt and traced downward. When the gut 
is found and brought to the surface, I look for a piece with a 
sufficient mesentery by passing the gut through the fingers. 
Of course this can only be done if the disease is in the rectum 
or the lower part of the sigmoid flexure. Generally the part 
of the sigmoid first pulled up has quite sufficient mesentery. 
If it is fixed to the back of the abdomen, there being a very 



TREATMENT OP CANCER OF THE RECTUM. 399 

short mesentery, I pull up as much of the gut as possible and 
stitch it to the wound, so that the intestine when opened (some 
days later) looks like the orifices of a double-barreled gun. 
This appearance is obtained by introducing the suture in the 
following way : A needle threaded with carbolized silk is 
passed through the mesentery close to the intestine, then 
through the abdominal wall on both sides at the middle of the 
wound, and the sutures are tied up tight. If there is little 
or no sigmoid mesocolon, I am obliged to pass the suture 
through the muscular and serous coats of the gut at its poste- 
rior part. Leaving a fair-sized knuckle of loose gut outside of 
the wound, I next sew the gut all around to the skin, passing 
the thread only through the muscular and serous coats. This 
is done very carefully, so as not to prick the mucous coat. 
Antiseptic dressings are then applied, pads being placed over 
the opening, so that if there is any vomiting the gut may not 
break away from the sutures." My friend Dr. Leon Straus, 
after seeing much of this work in Europe, believes in and 
extols Mr. Herbert Allingham's operation. 

The operation as done by Kelsey is described as follows : 
" An incision about two inches and a half long is made in the 
left groin, parallel with Poupart's ligament, about half an 
inch above it and well toward the lateral wall of the abdo- 
men, so far that the epigastric artery should not be seen in 
the operation. This incision is carried down to the perito- 
naeum, each successive layer being divided on a director, as is 
usual in operations on this part. Before the peritonaeum is 
opened, all haemorrhage from the wound should be stopped 
and the cut rendered as clean and dry as possible. The peri- 
tonaeum is then pinched up with forceps and nicked, a director 
is introduced, and the opening enlarged to the extent of an 
inch and a half. The descending colon should be in view im- 
mediately below the wound, and is recognized by the usual 
signs. When such is the case, the subsequent steps of the 
operation are comparatively simple, the incision into its 
wall and its union to the abdominal wound being accom- 
plished in the same manner as in the lumbar operation ; but 



400 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

when such is not the case, the bowel must be searched for, 
and it may be necessary to enlarge the original incision. The 
operation may be modified with advantage by stitching the 
parietal and visceral layers of the peritonaeum together, with 
sutures passing down to the submucous layer of the bowel, 
but not into its caliber. The wound may then be covered, 
and the opening into the bowel delayed from six to eight 
hours for adhesions to occur." 

The Author's Plan. — In some respects, especially the fixing 
of the gut, the plan which I have employed differs some- 
what from the authors that I have quoted. The first main 
point to be remembered in the operation is to escape the 
branches of the epigastric artery, and hence I make my in- 
cision higher than has been advised, save, perhaps, by Mr. 
Cripps. Indeed, I have never seen why we should not go just 
as high up the colon in making this incision as we might 
desire. If the gut is not found in cutting down at the usual 
site, of course there is no reason why the incision should not 
be carried higher up ; but I much prefer to make the original 
incision high enough at first to meet these demands. As a 
guide I take Cripps's imaginary line, which runs from the 
anterior superior spine to the umbilicus, and make an incision 
two and a half or three inches long, which crosses this line at 
right angles at about an inch and a half from the anterior 
spine. To those who are not in the habit of operating it is 
very well to mark this line with iodine, that it may be seen. 
Cripps has half the cut above and half below the imaginary 
line. I have found that by having the incision one third 
below and two thirds above this line meets the indication 
better. When the peritonaeum is reached I am careful not to 
tear it ; therefore, catching it up by forceps, I nick it just 
sufficiently with a knife to allow a fine-pointed scissors to 
enter it ; by which it is divided the full length of the cuta- 
neous incision. I do not admit my finger into the opening 
that is nicked, but lay it open in the manner described. I 
believe that the proportion is greater than one third that 
the large intestine presents itself ; but very often the small 



TREATMENT OF CANCER OF THE RECTUM. 



401 



intestines present, and the colon is only detected after a 
rigorous search. In many instances it is found up near the 
navel. There is but little difficulty experienced in detect- 
ing it, for its longitudinal bands and its convoluted sur- 
face readily indicate it. Having found the colon, I draw 
it up to the wound by means of my finger and thumb 
hooked under it, and I believe in drawing as much loose 
bowel as will come out without any force being used, and 
rapidly passing it again back into the cavity at the lower 
angle of the wound. During this act of passing the gut 
through the fingers a piece with sufficient mesentery should 
be sought. Now, instead of passing " a needle threaded with 
carbolized silk through the mesentery close to the intestines," 




inguinal eolotomy. (Alter Mathews.) 

I pass two delicate but stout steel needles, made for the 
purpose, through the abdominal integument on one side, then 
through the mesentery close to the intestine and out of the 
abdominal wall on the other side, catching only enough of 
the true skin to insure a smooth surface. For a time I used 
only one such needle, but I thought by passing two very close 
together, about a quarter of an inch apart, a better spur was 
obtained. These needles are made about live inches in length, 

26 



402 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

with a heavy blunt end at one extremity, and, after they have 
passed through in the manner described, they are secured by 
drawing the parts as tightly as desired, and then pressing a 
bullet upon them at the other extremity to insure their 
remaining in position. This idea was obtained by seeing 
Kelsey use, for a similar purpose, a silver wire in doing an 
inguinal colotomy. He did not claim priority in the use of 
it, nor did I hear him say to whom he was indebted for the 
suggestion ; but in talking to my friend Dr. W. T. Bull 




Inguinal colotomy. (After Cripps.) 

afterward, he mentioned that he had upon one occasion 
adopted a similar method. When these pins have been 
secured the operation is practically completed, but the pre- 
caution is observed to sew the gut to the skin with several 
sutures. It is very well, also, to stitch the two angles of the 
wound. A piece of rubber cloth is now laid over the wound, 
and iodoform gauze over this, and a moderately tight bandage 
is made to encircle the abdomen, to meet such symptoms as 
vomiting and great distention and prevent the breaking of 
stitches. After eight to twelve hours the exposed intestine is 
fixed firmly to the abdominal wall by lymph, and the gut can 



TREATMENT OF CANCER OF THE RECTUM. 403 

be opened then if necessary. Herbert AUingham says that 
there is generally a large quantity of gut, or rather walls of 
the gut, on both sides of the incision. This he removes by 
cutting it away until the edge of the gut is nearly on a level 
with the skin. This is quite a good idea, and yet if the ad- 
vice is adopted too indiscriminately, the mistake might be 
made of cutting away too much, for the walls will shrink to a 
certain extent. Patients after the operation are able to walk 
around the house in a few days. 

Condition of the Patient after Operation. — There is no use in 
denying the fact that the condition of a patient after an op- 
eration for colotomy, either by the inguinal or lumbar method, 
is a disgusting one. Nature never intended any such outlet, 
and, granting that the faeces are voided without trouble, the 
fact that the opening is in an unnatural place is enough to 
cause a mortification on the part of the patient. Cripps says, 
to suppose that a patient after colotomy is in a miserable con- 
dition is a delusion. It depends very much upon what can 
be termed a "miserable condition." I think that one can be 
rendered just as miserable mentally as physically, and, al- 
though the f a3ces do not constantly run away from the open- 
ing, the mind is constantly dwelling upon the fact that there 
is an unnatural outlet for the faeces. Therefore I wish to 
impress upon the reader's mind again the absolute impor- 
tance of describing the operation and its results to the patient 
before it is done. I have seen patients upon whom colotomy 
had been performed who said to me : "How long will it take 
for this opening to heal % " meaning how long would it take 
to close entirely. And this leads me to remark that all 
attempts at establishing an anus at the natural site after 
colotomy had been done have signally failed. To say the 
least of such attempts, they are, in the vast majority of cases, 
unsuccessful. Although I do this operation when I think it 
is imperatively demanded, yet after each one I question my- 
self whether it should have been done at all. Lately, while 
the guest of my friends Drs. John A. Wyeth, W. T. Bull, and 
other distinguished surgeons in New York, I found that with 



404 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

them the operation of colotomy was in great disfavor, and that 
they seldom practiced it. Senn speaks discouragingly of it. 
Therefore I can do no better than to urge upon all those who 
contemplate doing the operation to weigh with care the opin- 
ions of these distinguished men. 

Method of doing Lumbar Colotomy. — Allingham, Sr., gives 
some most excellent points in doing the lumbar operation ; 
therefore I shall take the opportunity of quoting from his 
work: "When about to operate, the patient should be 
placed upon a hard couch, in the prone position, with a slight 
inclination toward the right side, and a hard pillow is to be 
adjusted under the left side, so as to render the loins tense 
and prominent. Having by measurement found the place at 
which to make your incision (with its center quite half an 
inch posterior to midway between the anterior superior and 
posterior superior spine of the ilium, and midway between 
the last rib and the crest of the ilium), the structures 
should be very carefully divided, and this should be done 





Lumbar colotomy. 

slowly and deliberately, waiting until bleeding is arrested, 
so that the anatomical relation of the parts may be duly rec- 
ognized as the operation proceeds. I think it very desirable, 
though not absolutely necessary, that the fascia lumborum 
should be thoroughly made out, and, if possible, the edge of 



TREATMENT OF CANCER OF THE RECTUM. 405 

the quadrator lumborum muscle clearly exposed. If this is 
seen, a sharp-pointed bistoury should be passed beneath it 
and the muscle freely divided. When this is done the colon 
may be found. It is generally covered by fat, which may be 
mistaken for the gut ; but this error will be soon discovered, 
and is very easily rectified. It is of the utmost importance 
that the deeper incisions be kept the same length as the cut 
through the skin. If you do not attend this rule, by the 
time you reach the lumbar fascia you will be working in a 
deep triangular hole, the apex of which is farthest from you, 
and it will be almost impossible to find the gut, even if you 
have come down on the right spot. From personal experi- 
ence, and the many operations I have seen performed by 
other surgeons, I am quite convinced that this is the secret 
of overcoming one of the difficulties of the operation. After 
exposing a piece of intestine, and failing to see a longitudi- 
nal band, I make a small incision in the peritoneum, and 
convince myself, by finding a band, that it is the large in- 
testine. The posterior part of the intestine is then taken 
hold of, drawn to the surface of the wound, the gut being 
pulled out as far as possible, so as to obtain a good spur, and 
carefully stitched with interrupted sutures all round to the 
edges of the skin without perforating the mucous lining. The 
intestine may then be left unopen for some hours or, if ne- 
cessary, opened at once, provided it is carefully attached at 
every point to the surrounding edges of the wound." 

The after-treatment of lumbar colotomy is about the same 
as that of inguinal colotomy. I have stated that the former 
is the favorite operation with me in the majority of cases 
where colotomy is demanded. I shall not argue it further 
here, but in the chapter on disease in the sigmoid flexure it 
is again referred to. 

In a paper read by me before the Mnth International 
Medical Congress, which convened in Washington in 1887, I 
took exception to colotomy as a means of treating cancer of 
the rectum. In that paper I said : " It is after a careful sur- 
vey of all the reasons advanced by those who advocate co- 



406 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

lotomy in cases of cancer of the rectnm that I am constrained 
to differ from them, and to say that I do not believe that the 
operation is justified in these cases except under the rarest 
circumstances, if at all. " 

I am still of the same opinion. Too many people are 
being subjected to this horrible and disgusting operation 
that could be benefited equally as much by simpler means, 
for, as I have tried to demonstrate, the operation in itself 
promises but little, and is rarely called for. 

My conclusions in that paper before the congress were as. 
follows : 1. I do not believe that colotomy is justifiable in 
cases of cancer of the rectum proper except in the rarest 
instances. 2. In strictures or obstructions of the rectum, 
from whatever cause, located within three inches and a half 
of the external sphincter muscle, colotomy should not be 
done. 3. The operation is not warranted in cases of ulcera- 
tion of the rectum (unless of specific origin) and accompanied 
by strictures, located three inches and a half above the 
sphincter muscles. 4. I do not believe that in congenital 
occlusion of the rectum the operation is advisable, except 
by consent of the parents after the nature of the operation 
is explained. 5. In cases where the operation is looked upon 
as a dernier ressort I do not think it should be performed 
except for total obstruction located above the point men- 
tioned, and the growth not malignant. 6. When the rectum 
or sigmoid flexure is totally obstructed by syphilitic deposit,, 
colotomy is advisable. 



OHAPTEE XVIII. 

EXTIRPATION AND PALLIATIVE TREATMENT OF CANCER. 

The treatment by excision of the growth in cases of rectal 
cancer is not a new one. Lisfranc was among the first to 
recommend it. Others followed, not only doing the operation, 
but speaking favorably of it. No doubt in the first instances 
the operation was done in a crude way, for Velpeau after- 
ward modified the operation very materially, but it fell into 
disuse, and not until Marchand published his work on the 
subject, in 1872, was much interest taken in it by modern 
surgeons. Sir James Paget did much to revive the operation. 
In America, Roberts, Kelsey, Bull, and others have done 
a great deal in having it classified as a legitimate operation 
of surgery. Like all other surgical operations, it has been 
overdone, and the statistics have shown a fearful mortality. 
Billroth, especially, has shown what a dangerous operation it 
is. I take it that the great mortality is from the indiscrimi- 
nate manner of doing the operation, and not from the opera- 
tion itself. We seldom see cancer of the rectum until it has 
progressed so far that gland involvement and a general consti- 
tutional infection has taken place. Therefore the question of 
the utmost importance in consideration of the operation is 
the selection of cases. Like many other operations upon 
which discredit is thrown, it has not received that proper 
consideration from the profession which its importance de- 
mands, simply because the results shown have been very bad. 
If, however, we can see a cancer of the rectum in its incip- 
iency, in an otherwise healthy subject — one that is able to 
bear the shock, etc., incident to so grave an operation — then 
I consider the extirpation of the growth, or, more properly 



408 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



speaking, the excision of the rectum, as a perfectly legiti- 
mate and justifiable operation. Of course a very careful ex- 
amination should be made of the parts and also of the pa- 
tient's general condition. It may be not only that the opera- 
tion is unwarrantable because of the pathological change in 
the rectum, but the anatomical bearings have to be consid- 
ered. For instance, if the neighboring organs are implicated, 
such as the uterus, the vagina, prostate gland, etc., it is be- 
yond question that such a condition will intimidate us in the 
consideration of the removal of the growth. I have seen two 
cases lately that will illustrate my point. 

Case I. — A young lady actress 
was referred to me by a physician 
friend of this city. She gave me 
this history : About three years 
ago she complained of great pain 
in the rectum, with some swelling 
around the anus. A physician 
was called, who made an exami- 
nation, and told her that it was 
necessary to open a small abscess 
that was pointing inside the gut. 
This he did, but very little pus 
escaped. The swelling rapidly in- 
creased until the end of one week, 
when he informed her that she 
had a large rectal abscess which 
he proposed to open. This he also 
did, making his cut externally. 
From this cavity a great amount 
of pus was discharged, and she 
was confined to her room for three or four weeks. After 
the lapse of several months she was told that she had a 
fistula, the result of the abscess, and she was advised to 
go to an infirmary, where the operation for fistula with the 
knife was done. She is now filling an engagement in this 
city with a theatrical troupe, and, as I have said, came to 




Sarcomatous infiltration of rectum 
producing long tubular stricture 
(Ball.) 



EXTIRPATION AND PALLIATIVE TREATMENT OF CANCER. 409 

consult me, with the following symptoms : She prefaced by 
saying that she did not think the surgeon had done a good 
job in curing her of fistula, for she still had a discharge from 
her rectum, attended with pain which was aggravated by 
defecation, and that she had a harrassing straining at stool ; 
that she passed a good deal of mucus, some blood, and that 
she was compelled to wear a pad of cotton to prevent the 
staining of her linen by the discharge. I was inclined, from 
this description of hers, to believe that she had an unhealed 
fistula, and, in placing her upon the table for an examination, 
supposed I would find that state of affairs ; but, to the con- 
trary, I found a good cicatrix, which resulted from the former 
wound, and without any evidence of a sinus existing. I then 
anointed my finger and introduced it into the rectum, more 
for the purpose of finding an internal opening of the fistula, 
if such an one existed ; but, to my surprise, my finger came in 
contact at once with a hard, nodular growth situated in the 
septum and extending up for four or five inches. Upon 
further questioning her, she stated that in her straining 
effort at stool, what she took to be the womb prolapsed to 
such a degree as to be seen outside of the body, but, upon 
further investigation, I ascertained that it was the poste- 
rior wall of the vagina. Examining, therefore, this growth 
through the vagina, I found that it filled a large space in both 
the rectum and vagina, in the shape of a half -oval tumor. 
The uterus was fixed by plastic infiltration. Seeing that the 
patient had no idea of the enormity of the trouble, I advised 
her to finish the theatrical engagement at the earliest possible 
date, and to return to her home in Boston, when I would 
give her a letter to a surgeon of that city who would look 
after her case. 

Case II.— The second case was in consultation with Dr. 
Krim, of this city, and was seen a couple of hours after the 
first one. A woman, forty-nine years of age, weighing about 
one hundred and forty pounds, this being her usual weight, 
had complained of an obstruction in the bowel, with a diffi- 
culty in having an evacuation. She said that very often she 



410 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

felt a sharp pain dart through her back or abdomen, but it 
was gone in a few minutes ; that she strained greatly at stool, 
but never had a well-formed action. Outside of these symp- 
toms she was in a comparatively good state of health, 
although she traced her symptoms as far back as six years. 
Dr. Krim had already told me of the location of the tumor in 
the rectum, and, upon my inserting the finger, it was just as 
he had stated— located in the septum, and extending up the 
bowel five or six inches. Although this tumor could, to a 
certain degree, be circumscribed, its anatomical bearings were 
such as would not warrant its extirpation. We both agreed, 
therefore, to tell the husband of the condition that existed, 
and put the woman under palliative treatment. 

These two cases were very similar in nature, affecting very 
much the same parts of the rectum, both embracing the vagina 
and uterus in the disease. Had only the lower portion of the 
septum been involved in either case, I would have been in- 
clined to extirpate the growth, for I am sure that such impli- 
cation does not contra-indicate the operation ; but a cancer of 
the rectum involving its dorsal aspect is more favorable for 
the operation by excision that when situated in front. It 
must be remembered that in doing the operation of excision 
for cancer in or around the rectum, a half-way operation does 
no good at all, but, to the contrary, a great deal of harm, 
Suppose, for instance, that in either one of the two cases just 
cited I had removed a portion of the septum which contained 
the major part of the tumor. With the septum gone, the 
sphincter muscles interfered with, and a great wound result- 
ing, the patient would have considered herself in a far worse 
condition than when she came to me, for in neither case were 
there very pronounced symptoms, and both patients were at 
the time able to attend to their regular duties, one as an act- 
ress and the other as a housekeeper. Any surgeon will see 
at a glance how absurd it would have been to have done a co- 
lotomy on either one of these patients. There was no obstruc- 
tion to the passage of f reces, and no particular pain ; and yet I 
am sure that colotomy has been done on just such cases. Mr. 



EXTIRPATION AND PALLIATIVE TREATMENT OP CANCER. 41 1 

Cripps, in the tables appended to his Jacksonian essay, re- 
cords the following mortality : Ont of fifty -three cases of 
excision of the rectnm, forty -fonr recovered and nine died, 
giving a mortality of about seventeen per cent. Kelsey, from 
a collection of one hundred and forty cases, gives one hun- 
dred and eighteen recoveries and twenty -two deaths, being a 
mortality of about nineteen per cent. Billroth reports his 
cases at forty-five, with nineteen deaths, being over forty per 
cent mortality. Cripps has operated himself in thirty cases, 
with twenty-eight recoveries and only two deaths, a mortality 
of less than seven per cent. 

The difference in mortality, as recorded by Cripps and 
Kelsey, opposed to that of Billroth, must be due to the se- 
lection of cases in the reports of the two first-named gentle- 
men, and an indiscriminate collection by Billroth, for we are 
well aware of the distinguished surgeon's ability. It is very 
well to consider under this head the causes of death, and I 
can do no better than to quote from Billroth's cases, viz. : 

Peritonitis 15 ) 

Cellulitis 5 { 

Septicaemia 4 

Erysipelas 3 

Exhaustion 4 

Haemorrhage 1 

Not stated 1 

Total 33 

Now, it will be observed that fifteen of these deaths were 
from peritonitis, five from cellulitis, four from septicaemia, 
and three from erysipelas, making a total of twenty-seven. 
In other words, twenty- seven deaths out of thirty -three oc- 
curred from septic infection, for all of these can be so called, 
not to speak of the four reported as occurring from exhaus- 
tion, which were possibly also septic. The question naturally 
arises here whether a thorough and rigid antiseptic operation 
was done in each of these, and if not, how far would it have 
gone in preventing death by averting septic infection. Of 



412 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

course it is to be considered that we are dealing with an al- 
ready septic local condition if not with a general one. In any 
event, however, it should never be forgotten that the neces- 
sity for an antiseptic operation here is imperative. In so 
formidable an operation a thought of grave consideration is, 
how much is the patient to be benefited by it, granting that 
he survives the operation % In Cripps's Jacksonian essay 
forty-four cases of recovery from the operation are record- 
ed ; the subsequent history, however, is not given in six- 
teen of these cases. The results are given for the remaining 
twenty-eight, and are as follows : Three of these were de- 
ducted from the nature of the disease being doubtful. Of 
the remaining twenty -five cases no recurrence had taken 
place in eleven instances, after intervals varying from a few 
months to some years. In three of the cases over four years 
had elapsed without recurrence. In the remaining fourteen 
cases recurrence took place after intervals varying from four 
months to three years. In some of these the recurrence was 
of a very trivial nature, and was easily removed by a second 
operation, while in others the patient died of a general can- 
cerous cachexia. In Kelsey's statistics, out of one hundred 
cases which recovered, six cases are reported as permanent 
cures, in which there had been no return in ten years. Now, 
if we were to come down to a close investigation of these 
reported cases, we might suggest, with a certain degree of 
plausibility, that perhaps in the forty cases of recovery re- 
ported by Cripps, sixteen cases, whose subsequent history 
was not reported, died of the disease. Out of the remaining 
twenty-eight cases three were deducted, because the nature 
of the disease was doubtful ; therefore, giving the patient 
the benefit of the doubt, it might be inferred that they 
were not cancer. Out of the remaining twenty-five cases no 
recurrence had taken place in eleven instances after inter- 
vals varying from a few months to some years. ISTow, a few 
months extends all the way from two months to twelve, and 
if patients are to have a recurrence of cancer in " some 
months,' 7 whether it be two or twelve, we must admit that 



EXTIRPATION AND PALLIATIVE TREATMENT OF CANCER. 41 3 

the operation was of doubtful propriety, because the patients 
would have lived that length of time, and perhaps longer, 
without any operation. In three of the cases only, after 
four years had elapsed, was there no recurrence. Cripps 
does not say at what stage of the disease the operation was 
done in these three cases, but we are to suppose that they 
were cases which admitted of an operation, without any 
serious anatomical complication, and certainly without con- 
stitutional infection. Well, it will not be denied that pa- 
tients often live from four to six years after cancer has devel- 
oped in the rectum. So, as far as the saving of life was con- 
cerned, the operation in these cases did not do it. In the 
remaining fourteen cases recurrence took place after intervals 
varying from four months to three years. The same line of 
argument can be used here as that in reference to the three 
cases mentioned. True, it can be said that in the interim 
between the healing of the wounds after the operation and 
the recurrence of the cancer these patients enjoyed an im- 
munity. I would ask, an immunity from what % I have 
already cited a number of cases of pronounced cancer of 
the rectum where pain was not sufficient to complain of, and 
the distress was not great enough to prevent the ordinary en- 
joyment of life. Now, when we consider that in this opera- 
tion, as performed by Cripps, there was serious injury done 
to the sphincter muscles, perhaps resulting in incontinence of 
faeces and the inability to control the gases, perhaps the de- 
struction of a portion of the septum of the female — things 
which follow as a necessity after these operations — I must 
confess my inability to see or understand the advantages de- 
rived from it. In Kelsey's statistics, out of one hundred cases 
which recovered (from the operation, I suppose he means), six 
cases are reported as permanent cures, in which there had 
been no return for ten years. Besides these, in twenty-four 
other instances the patients were alive and well, without sign 
of return, at intervals varying from one to six years after the 
operation. I remember once in discussing the injection plan 
of haemorrhoids, where a physician was claiming that he had 



414 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

cured quite a number of cases by it, I asked him how he knew 
that they were cured, and he replied that there had been no 
further protrusion. I then asked him if he had examined the 
rectum to see whether there were any tumors then existing. 
He replied that he had not. ISTow, in the statistics that I 
have just quoted, where patients are said to have been alive 
without sign of the return of the disease, it might be asked 
were these patients examined carefully during said interval 
to find out whether there was any return or not ? We know 
very well that an ulceration, benign or malignant, can exist 
above the sphincter muscle, and give very little evidence of 
its presence. 

It will be seen, then, that the operation does not hold forth 
any great inducement, and a surgeon should consider well his 
case before undertaking it. Cripps says : ' ' When compared 
with operations for malignant disease undertaken in other 
parts of the body, excision of cancer from the rectum gives 
at least as good results." 

I certainly can not coincide in this belief. Of all parts of 
the body, the most difficult from which to remove a cancer 
is certainly the rectum. Its intimate relation with the other 
organs, its location in reference to cellular tissue, its peculiar 
office, together with the fact that the operation has to do 
with the function of the sphincter muscles, all go to make up 
a difficulty which is hard to surmount. In addition to this, 
we are to consider that it is sometimes an impossible thing, 
even with the scrutiny that we can command, and with the 
finger as a guide, to determine whether a nodule or an infil- 
tration does not exist higher up the gut than the portion 
excised. If such does exist we must admit that the opera- 
tion, in so far as saving life, is a failure. Certainly it is 
much easier to determine this question at other points, and 
certainly a more radical operation can be done for growths on 
the external portion of the body than on those in a cavity 
like this. 

Plan of Operation. — The plan of operation has been much 
discussed by surgeons, but my experience in removing 



EXTIRPATION AND PALLIATIVE TREATMENT OF CANCER. 415 

growths from the rectum, or, more properly speaking, of ex- 
tirpating the rectum, has taught me that no one special plan 
can be followed. Between that of the German surgeons of 
removing the entire rectum up to the sigmoid flexure, and 
the English surgeons of restricting the operation to a very 
limited extent, I believe that a middle ground can be estab- 
lished and practiced, based upon a true pathology. It is an 
axiom in surgery that in operating for cancer the whole 
growth must be removed, together with the glands that are 
involved. Let us take this axiom as our guide in rectal sur- 
gery. If the growth extends beyond the point where it is 
prudent to operate, it is best not to attempt its removal. 




Excision of rectum. (Allingharn.) 



Cripps makes the point that the operation is of doubtful pro- 
priety when the disease involves the upper part of the recto- 
vaginal septum, where it is covered with peritonaeum. I do 
not consider this injunction as meaning that it is so danger- 
ous to open the peritonaeum, but that this membrane being 
involved in the disease renders the operation useless. If 
there is no fear of the invasion of the peritonaeum, an admi- 
rable operation is afforded by Kraske's suggestion, enabling 
us to remove much of the length of the rectum. The chief 
argument in favor of his operation is that the entire length 



416 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

of the rectum can be removed without disturbing the sphinc- 
ter muscles. Incontinence of faeces, the result of injury to 
these muscles, is the one great objection to any other mode 
of operating. Kraske's operation is admirably suited to can- 
cerous tumors of the rectum. It consists in resecting the dis- 
eased part through an opening made at the left side of the 
sacrum. This operation of course is only applicable in a cer- 
tain class of cases ; for instance, when the sigmoid flexure is 
involved it would be of no use. If the operation is suggested 
for cancerous stricture situated in the lower part of the rec- 
tum, I would suggest that proctotomy wonld be a better op- 
eration. According to his method, the soft parts are divided 
in the median line from the second sacral vertebra to the 
anus. The muscular attachments to the sacrum are divided 
as far as the edge of the opening on the left side. The coccyx 
is removed, the attachments of the two sacro-sciatic ligaments 
to the sacrum are cut, and the soft parts drawn to the left 
side. If still more room is necessary, it may be gained by re- 
moving a part of the lower left side of the sacrum. If the 
bone be divided on a line beginning on the left edge at the 
level of the three posterior sacral foramina, and running in a 
curve concave to the left, through the lower border of the 
three posterior sacral foramina, and throngh the fourth to the 
left lower border of the sacrum, the more important nerves 
are not injured, and the sacral canal is not opened. In this 
way the lower part of the rectum as far as the sigmoid flex- 
ure may be removed. It will be found, however, in this op- 
eration that the dissection is a very difficult one. Alexander 
modified this operation, the chief points being that he ex- 
sected the coccyx and all of the sacrum necessary to a certain 
limit. Experimenting with the two operations, I much pre- 
fer Kraske's. I have removed as mnch as Hve inches of the 
rectum by simply removing the coccyx, making a deep and 
long dorsal incision, and then practicing a thorough dissec- 
tion of the gut. The one great object in both these operations 
is to keep the sphincter muscles and anus intact. 

To those not accustomed to doing this operation, or who 



EXTIRPATION AND PALLIATIVE TREATMENT OF CANCER. 41? 

perhaps have never seen it done, it would appear from the 
description to be one of enormous magnitude, and yet, by 
doing it expertly, it is surprising how small a wound is made. 
Any operation looking to the removal of the rectum for 
cancer must be considered a very serious one, and it has met 
with but little favor in this country. Gerster especially, 
though a positive and strict antiseptic surgeon, is not pleased 
with the operation, and many other American surgeons look 
upon it with disfavor. In speaking of an operation for the 
removal of cancer of the rectum, I refer, of coarse, to the 
radical operation ; for, unless this is done, it would be but 
temporizing, and, in lieu of any such effort, I would much pre- 
fer to divide the gut in the dorsal median line, as advised by 
•Verneuil. I believe that in many cases of cancerous stricture 
it would do equally as much good as either colotomy or ex- 
tirpation, having the advantage over both of these that it is 
much less serious in its consequences. To do the operation 
indiscriminately would be both unwise and hazardous. Our 
foreign confreres, who boast of such splendid results following 
the operation, must be credited with more enthusiasm than 
discretion. Nussbaum reports cutting out the rectum, a por- 
tion of the urethra, prostate gland, and the base of the blad- 
der, and says the patient recovered all his functions and lived 
three years. I can not understand how, with a portion of the 
urethra, the prostate gland, the base of the bladder, and the 
rectum gone, all the "functions" of the man could be recov- 
ered. Such operations are to be deprecated. It should be a 
positive rule, in selecting cases of cancer of the rectum for ex- 
tirpation, that if more than five inches of the gut are invaded 
the operation should not be done. Especially is this true if 
any evidence exists of constitutional infection. When the 
growth is beyond the reach of the finger, I never advise an 
operation. Dr. W. Alexander, in the Liverpool Medico- 
Chirurgical Journal, reports what he is pleased to call a new 
method for removal of cancer of the rectum. It consists 
mainly in the removal of the coccyx, together with a portion 
of the sacrum. But as this form of operation has been de- 

27 



4:18 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

scribed under the head of Kraske's operation, it is not neces- 
sary to give it any further mention here. Indeed, if the 
operation can be done without the removal of the coccyx or 
a portion of the sacrum, they should not be removed. Alex- 
ander says : " The piece of sacrum and coccyx removed are 
not missed in the least by the patient, so nothing is sacri- 
ficed." Even granting that this is true, if their removal is not 
an absolute necessity, it is best to do the operation without 
interfering with them. 

If the purpose is to obtain more room in operating, it can 
be done by making a deep dorsal cut down to the sacrum, as 
suggested by Allingham. It is a common custom with oper- 
ators, after the removal of the growth, to pull the gut down 
and stitch it to the true skin. I think it an error to make 
this a rule, for two reasons : 1. In many cases, if this is done, 
suppuration takes place, the stitches detach, and sepsis is 
invited. 2. If the open method is practicable, free drainage 
can be had, and the consequent cicatrix is a wonderful ad- 
vantage in controlling the faeces. I will take occasion here 
to speak of a case of cancer of the rectum, lately operated on 
by me, which will emphasize two points. First, that cica- 
trization may take the place of the sphincter muscles to a 
wonderful degree, at least to that extent to control the 
actions. Second, that the plan of not pulling down the gut, 
or stitching it to the true skin, has advantages over the usual 
method. 

Case. — Mr. A. was referred to me by Dr. L. Beecher 
Todd, of Lexington, Kentucky. The patient was a male, 
sixty-two years of age, six feet tall, and of slender build. 
Family history revealed nothing, so far as cancer was con- 
cerned. Three years ago he first noticed evidences of rectal 
trouble — loose bowels, severe lancinating pain, tenesmus at 
stool, and discharges of mucus and blood. He consulted a 
traveling doctor, who told him that he had piles, and was 
treated by the injection of carbolic acid into the part that 
presented. He was not benefited by this treatment. Up to 
this time he had lost forty pounds of flesh. 



EXTIRPATION AND PALLIATIVE TREATMENT OF CANCER. 419 

Surrounding the entire anus was a hard nodular growth, 
extending fully two inches into each buttock and well into 
the perinseum, and also up over the coccyx. A portion of 
this mass was ulcerated. An effort to introduce the finger 
showed nearly total occulsion at the anus. Some force being 
used, the tissues gave way and permitted the finger to enter. 
It was then revealed that the tumor extended about four 
inches up the rectum, around its entire circumference. JSTo 
infiltration could be detected beyond this. Extirpation of the 
growth was advised and consented to. It was done the next 
day, after the following manner : The patient had a bath, and 
the parts were washed and sponged with a hot solution of 
bichloride of mercury ; chloroform administered, the opera- 
tion was begun by making an incision, starting at a point 
well up over the sacrum, which was carried around the left 
side to the perineal line. Beginning again at the sacrum, a 
similar incision was carried around the right side. A careful 
dissection was then made of the entire tumor, all bleeding 
vessels were secured, and tied as the operation proceeded. I 
ablated fully four inches of the rectum. Securing a good hold 
on the mass, I cut the tumor off, removing it in its entirety. 
In size it was about as large as a good-sized orange. Not 
more than two ounces of blood were lost during the operation. 
The wound was constantly irrigated with the hot mercuric 
solution. All arteries were tied, and the oozing was checked 
with hot water. Iodoform gauze, well dusted, was packed 
into the gaping wound, which would easily admit the fist, a 
layer of bichloride gauze was placed over the parts, a bandage 
applied, and the patient put to bed. It required forty min- 
utes to complete the operation. The dressings were not re- 
moved for four days, at which time the patient had a large 
natural action — the first one form any months. Each day 
thereafter the wound was syringed by alternating the solu- 
tion of the bichloride of mercury (1 to 5,000) with a solution 
of eampho-phenique, and dressed after each irrigation as sug- 
gested. He made an uninterrupted recovery. In five weeks 
the large wound had closed. By this time he had gained 






420 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

flesh and took a trip home, remaining there several weeks. 
He came back to Louisville to consult me in regard to the 
contraction of the anus. He informed me that he had perfect 
control of his actions. His appetite and digestion were good, 
he had taken on additional flesh, and expressed himself as 
being very much gratified at the result. Before the opera- 
tion he was unable to walk ; he now walks with ease and 
rapidity. When asked about his ability to control his 
actions, he replied that he could do so perfectly, the only 
objection being that he felt that the contraction was too 
great. This was overcome by gradual dilatation. 

I think this case illustrates several points of interest in 
the discussion of the different methods of operating for the 
relief of cancer of the rectum. These who advocate colotomy 
in cases of this kind would have opened the colon, established 
an artificial anus, and left the growth in the rectum. Was 
it not best to extirpate the tumor % I think so, for the follow- 
ing reasons : 

1. If colotomy had been done, leaving the tumor, the op- 
eration would not have prolonged life, except in the way of 
overcoming the obstruction. 2. Pain would not have been 
relieved so radically as by extirpation. 3. The operation, 
with its attending results, would have been more disgusting 
to the patient. 4. The extirpation relieves pain, overcomes 
the obstruction, and prolongs life. 5. The healing process 
being complete, the tumor gone, the patient's mind is re- 
lieved. With colotomy the tumor would have remained, 
fresh inroads have been made, and a disgusting condition 
presented in the side. 

It will be seen that I have not taken a very favorable out- 
look in regard to either colotomy or extirpation as a means 
of treating cancer, and yet, so far as a radical operation is 
concerned, these are the only two that can be considered. I 
must confess that when a patient comes to me suffering from 
pronounced cancer of the rectum I am at a loss how to ad- 
vise him. It is a terrible and melancholy condition, for 
which the surgeon can promise but little, and yet, if the pa- 



EXTIRPATION AND PALLIATIVE TREATMENT OF CANCER. 421 

tient is willing to assume the risk of an operation after it has 
been fully explained to him, why, of course, we have no al- 
ternative but to perform it. 

Whereas the two operations named are regarded as the 
only two looking to the radical relief of the patient, I have in 
several cases adopted another plan, and in one case especially 
with a remarkable degree of success. I refer to linear proc- 
totomy and scraping away the growth. 

Case. — About ten years ago I was called to see a gentle- 
man who resided in this city, to examine him for rectal 
trouble. In company with his physician, I made a careful 
examination, and detected, about an inch and a half above 
the external sphincter muscle, a hard nodular growth about 
the size of an English walnut, although not so oval. I rea- 
soned by exclusion that the growth was malignant. It was 
located dorsally, and seemed to be closely attached to the 
soft structures, but not to bone. The mucous membrane was 
movable over it. Taking into consideration its locality, and 
that it was easily circumscribed, I suggested to the physician 
that we scrape it out. The patient was put under chloro- 
form and the sphincter muscles divulsed, when I encircled the 
growth by an incision. Beginning at its base with a sharp- 
pointed knife, I cut away a portion of it with curved scissors. 
But for reasons that are apparent, I believe that the scraping 
process was better than to have tried to dissect it away. I 
therefore took a stout scoop, and, by taking time, I carefully 
scraped out all the diseased tissue. The cautery-iron was used 
to stop haemorrhage, iodoform gauze placed in the wound, and 
a pad of cotton put over this. I removed this plug and dress- 
ing on the third day. I did not give a favorable prognosis, 
but the wound healed finely, and I had an opportunity of 
watching this case for five or six years, and there was no re- 
turn. Of course this operation can not be done upon growths 
located higher up the rectum, but I am satisfied that where 
they are located within close reach, this is quite a good op- 
eration to do. 

Palliative Treatment. — It is a very difficult thing to say just 



4:22 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

what a surgeon means by palliative treatment for cancer of 
the rectum. Certainly the operation of colotomy does noth- 
ing more than palliate the disease, for the cancer is left in the 
rectum, no attempt having been made to remove it, and of 
course it goes on in its terrible ravages until the patient suc- 
cumbs by death. It can only be claimed for the operation 
that it palliates the tenesmus, the pain, the distress, and pos- 
sibly enables the patient to live a little while longer. There- 
fore, when we consider any operative procedure that looks to 
a cure of a patient who has cancer of the rectum, extirpation 
of the growth is the only one that meets, or tries to meet, 
such an indication ; but, as we have remarked, the mortality, 
in even selected cases, by excision has been very fearful, and, 
besides, the operation has its serious defects. Nor have we 
been inclined to do colotomy in these cases, for the reasons 
already mentioned ; therefore, what are we to do with this 
unfortunate class of patients % Some relief must be afforded 
them. Every once in a while we hear of the discovery of 
some special medicine which is said to have a direct effect in 
curing cancer, either locally applied or taken internally. All 
such have proved utterly worthless in the hands of the physi- 
cian. As the disease advances, the tumor enlarges, the cali- 
ber of the rectum is encroached upon, and, before we know it, 
a strictured condition exists. Frequently total occlusion will 
result from a stricture in this cancerous mass, located within 
reach of the finger, and oftentimes just within the verge of 
the anus. I have known patients suffering from this con- 
dition to endure great torture for months from the fact that 
the attending physician had not detected it, when a very 
simple examination would have revealed the condition. The 
surgeon, when called to such a case as this, is naturally in- 
clined to overcome the obstruction by means of his knife, and 
I wish emphatically to say that when the knife is contrasted 
with the bougie in the treatment of such a stricture, the pref- 
erence must be given to the knife. It is only with the sur- 
geon then to determine whether he will divide the stricture 
by an internal incision, or whether he will do posterior linear 



EXTIRPATION AND PALLIATIVE TREATMENT OF CANCER. 423 

proctotomy, which includes the division of not only the 
stricture but of the external parts. I believe that it depends 
altogether upon circumstances which is the best. I have 
practiced both methods very often. Having but little faith 
in colotomy as a means of treating cancer, and regarding ex- 
tirpation of the rectum as a serious operation, but the better 
plan of the two, I very naturally fell into ameliorating the 
patient's condition by watching the symptoms, and, when ob- 
struction took place, to overcome it with the knife. And I 
must say that, in the division of the stricture resulting from 
cancer located close to the anus, I favor the internal di- 
vision of it over posterior linear proctotomy. If there be a 
decided stricture in the mass that can be well defined and 
made out by the finger, I believe that its simple division on 
the inside of the sphincter muscle will overcome the obstruc- 
tion, and will not result in any harm. I do not mean to say 
that the cut should be carried deep into the growth or the 
tissues, for I quite agree with the authors who say that if 
this is done it creates a receptacle for the lodgment of fseces, 
and would accomplish more harm than good ; but time and 
again I have overcome obstruction of the gut in this manner, 
and given great ease and comfort to the patient. But if it is 
desirable to do a more formidable operation, and the nature 
of the case is entirely different, then I believe more good can 
be done by making a division of the external parts along with 
the posterior cut. I am cognizant of the fact that authors 
have recorded that, after even slightly nicking the stricture, 
abscesses have resulted. Curling reports such a case. I 
know, too, that it is also said that peritonitis may be ex- 
cited, but I believe that either one of these conditions is the 
rarest of accidents, if the cancer is located in the lower part 
of the rectum and the stricture is within easy reach of the 
finger. We are often tempted to do this operation when the 
stricture is located higher up. One can understand very 
readily how peritonitis might result from the division of a 
stricture in such a location, and I had a death follow in my 
practice from doing it. 



424 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

Case. — A man was brought to me from an adjoining State 
who was suffering with a cancer that nearly completely filled 
his rectum. He had glandular enlargement and constitu- 
tional infection. He was able to walk about, and appeared 
at my clinic at the Kentucky School of Medicine. I exam- 
ined him before the class, and found a very close stricture, 
which almost prevented an evacuation of the bowels. I had 
him removed to an infirmary, and the next day did an inter- 
nal proctotomy, washing the bowel after and during the 
operation with a solution of bichloride of mercury. He did 
well until the fourth day, when he took on an active peri- 
tonitis, and died two days later. Of course I only expected 
a temporary relief from this procedure, and, although I did 
not expect a fatal result, I did not have much to censure my- 
self for, because the man could not have lived very long in 
the condition in which I found him. It might have been 
better to have done a colotomy, but that operation in this 
case could have promised but little. It is the only fatal case 
that I have ever had result from either the internal or the 
external division of a stricture. 

As I have suggested, something must be done for this class 
of patients in the way of palliation after the disease is so 
advanced as to cause great pain or distress. So far as the 
local treatment is concerned, we can not do better than to 
keep these parts as clean as possible, washing out by daily 
injections the accumulated feces and the discharges from the 
mass. It will be necessary often to throw the water above 
the stricture by using a No. 3 or 4 Wales rectal bougie, and, 
even if the water is passed out at once, it accomplishes some 
good in washing away the debris. As a local application, I 
am in the habit, after washing out the rectum as suggested, 
of throwing the following above the stricture, if possible, 
through the tube. 

^ Olive oil gj; 

Iodoform gr. x . 

This is often retained, and gives some comfort to the patient. 

It is presumed that we are now dealing with a class of pa- 



EXTIRPATION AND PALLIATIVE TREATMENT OF CANCER. 425 

tients where colotomy, extirpation, and even proctotomy have 
been thought unwarrantable. Premising that this is true, I 
must differ from the authors who claim that we should be 
chary about the administration of opium. Cripps says : 
"If the nights are restless, a single dose of opium, varying 
from ten to twenty drops of liquor opii, is valuable, but I 
have the greatest dislike to the frequent administration of 
opium both day and night in increasing doses. The craving 
for the drug becomes such that the patient will magnify his 
sufferings to any extent in order to obtain a frequent dose. 
The mental depression and utter demoralization thus pro- 
duced cause far more misery to the patient and distress 
to the friends than the physical suffering it is supposed to 
relieve. Employed in an indiscriminate manner, I consider 
opium as one of the greatest curses to which suffering hu- 
manity can be subjected." 

To the latter clause of this quotation I most heartily con- 
cur, if he refers to the indiscriminate manner of prescribing 
opium for every-day complaints. I believe that physicians 
are often responsible in making opium liabitues of their pa- 
tients. Many young women, I am sure, have fallen into the 
habit by having had opium prescribed for them during the 
pain that is excited by faulty menstruation, etc. Such pre- 
scriptions should meet the condemnation of all doctors. But, 
instead of considering opium as a great curse, if used to sub- 
due the pain incident to an incurable cancer, for which noth- 
ing can be done looking to its radical relief, I consider it the 
greatest boon ever given to the human family. Just as well 
say that if a man is shot in some vital spot, and must die 
in consequence, his agonizing pain should not be stopped 
by the use of opium. These people, of whom we are now 
speaking, have no hope for life, and there is no necessity for 
keeping from them that which will lull and quiet this terrible 
agonizing pain to which they are subject ; and, after a trial 
with many drugs, I am satisfied that there is not a single one 
comparable to opium for this purpose. 

What matters it if a craving be established for the drug ? 



426 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

I would just as soon think of keeping a dying fever patient 
from slaking his thirst with cold water. These patients are 
as surely dying from cancer, and are in a state of torture ; 
and therefore I say, even if they become habitues of the drug, 
let it be so. Surely the friends can not be distressed so much 
over the fact that they are using opium to quiet them as to 
see them suffering from the torments of pain. To such peo- 
ple I am in the habit of beginning with a very small dose of 
opium. Oftentimes the eighth of a grain of morphine will be 
sufficient to quiet them for hours, and may not have to be 
increased for some time. Then a sixth, a fourth, a third, a 
half -grain, and, if toward their declining days, two grains, five 
grains, ten grains, or let it be twenty grains, I feel that I have 
done them a service in relieving their body and mind of a 
terrible affliction. 



CHAPTER XIX. 

DISEASE IN THE SIGMOID FLEXITKE. 

Many books and very many elaborate articles have been 
written on diseases of the rectum, but very few dissertations 
have appeared on diseases of the sigmoid flexure. It is true 
that in the works on both the practice of medicine and sur- 
gery the flexure is incidentally referred to as a seat of disease, 
especially that of malignant trouble, but authors are singu- 
larly silent in dealing with these diseases, both as to diagnosis 
and treatment. Unfortunately, if cancer be detected in the 
sigmoid flexure, but little if anything can be done for its 
relief. Such has been the edict of surgery in all time. Sev- 
eral reports have appeared of the removal or resection of the 
flexure under such circumstances — a very notable one by Dr. 
W. T. Bull, of New York city. 

As to palliative measures, but few have been suggested 
except in a general way. Of the importance of this portion 
of the large intestine, if attacked by disease, no one will ques- 
tion ; but the great trouble has been either to diagnosticate it 
when it does exist, or to treat it if detected. In my experi- 
ence as a rectal surgeon, no class of patients has given me 
as much trouble as those suffering from vague symptoms of 
disease in the sigmoid flexure, and I am also convinced that 
they are much more common than is supposed. 

From its anatomical construction and situation it is easily 
seen that disease here would be of a much more serious nature 
than if located in the rectum. Total obstruction could much 
more readily and surely take place, and the consequences 
would be more disastrous. The sigmoid flexure has a differ- 
ent construction from the rectum. It is generally located in 



428 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

the left iliac fossa. Its fold of peritonaeum is attached in the 
fossa, and is long enough to allow the gut to hang over the 
brim into the pelvic cavity. At the lower end of the flexure 
the fold is quite short, and holds the part up close to the 
sacro-iliac symphysis. It can be seen, then, that the sigmoid 
flexure hangs down in the pelvis like a bag when it is not 
distended. The rectum, at least its lower half, is flxed ; the 
sigmoid is loose. The one is accessible, the other is supposed 
to be inaccessible. We have stated that the anatomical con- 
struction of the rectum evidences that it never was intended 
as a receptacle of faeces between the acts of defecation. In 
considering the physiology of this act, O'Beirne said that if 
the calls of Nature are not heeded, the faecal mass is lifted 
back into the sigmoid flexure, and there remains until the 
next effort is made. During this time, of course, the watery 
constituent of the mass is reabsorbed, and the remainder is 
left in a dry, hardened condition. What could be the source 
of greater mechanical irritation than this ? Is it any wonder, 
then, that a congestion, an inflammation, and, lastly, an ulcer- 
ation of the gut could occur ? 

Although the mucous membrane of the large intestine is 
more like that of the stomach than like that of the small in- 
testines, a very correct idea of the anatomical character under 
disease can be had by studying that of chronic enteritis — viz. : 
"The intestinal mucous membrane, when it has been the seat 
of inflammation for any prolonged time, is thickened, tough, 
and of a gray or almost black color from a deposition of pig- 
ment due to the chronic congestion. The epithelial cells are 
cloudy and ill defined, and there is an infiltration of the mu- 
cous and submucous layers with new round -celled tissue 
passing into the stage of connective tissue ; hence the thick- 
ness and toughness. The lymphoid follicles are prominent 
and hard, and the intestinal glands are frequently blocked 
with cells and secretion and form solid, minute, though per- 
ceptible masses. The surface of the membrane will be more 
or less covered with a viscid, glairy mucus, containing pus 
and imperfectly formed epithelial cells, which may be fre- 



DISEASE IN THE SIGMOID FLEXURE. 429 

quently voided in the form of complete casts of the tube, 
and this is particularly the case in the pellicular form of co- 
litis. Sometimes the muscular coat is thickened from con- 
nective-tissue formation. As a rule, therefore, the bowel is 
increased in thickness. It is unusual for a chronic inflamma- 
tion of the intestine to exist in adults without coincident ulcer- 
ation " (Allingham). Cruveilheir compares the mucous mem- 
brane of the large intestine and the stomach in the following 
words : " When examined with the microscoj^e, the mucous 
membrane of the large intestine is seen to have no villi ; but 
we find the same appearance as in the mucous membrane of 
the stomach — an alveolar or honeycomb arrangement. In the 
stomach this character is due to the pressure of alveoli, in the 
bottom of which perpendicular tubuli open. In the large in- 
testine there are no pits, but the alveolar appearance is pro- 
duced by the opening of numerous tubes, analogous in form 
and direction to the tubuli of the stomach and the follicles of 
Lieberkuhn in the small intestine." 

Although these statements are undoubtedly true, they 
have a bearing only from a physiological view, and not when 
we consider the changes that take place in the mucous mem- 
brane in disease ; hence I have cited the well-known pa- 
thology which is induced in chronic enteritis to illustrate 
the condition in the sigmoid flexure when undergoing the in- 
flammatory act. 

There are two special points that I wish to call attention 
to in considering inflammation of the intestine: 1. "The sur- 
face of the membrane will be more or less covered with a 
viscid, glairy mucus, containing pus and imperfectly formed 
epithelial cells, which may frequently be voided in the form 
of complete casts of the tube, and this is particularly the case 
in the pellicular form of colitis." 2. " It is unusual for a 
chronic inflammation of the intestine to exist in adults with- 
out coincident ulceration." 

In regard to the first point, it is so much like a condition 
that I have often seen in treating ulcerations or inflammations 
of the sigmoid flexure, that I will detail a few cases here. 



430 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

Case I. — Mrs. B., the wife of a letter-carrier, was referred 
to me, suffering from what was supposed to be a chronic 
catarrh of the bowel. She said, in detailing her case, that 
she would frequently through the day feel a desire to go to 
stool, and would pass nothing but " matter." By this expres- 
sion she meant either pus or mucus. Patients are never able 
to tell the difference. It was not that she had to go to stool 
often that worried her, but rather the amount of this "stuff" 
that she passed. Upon close questioning, she said that she 
passed as much as a pint at a time. Believing this to be an 
exaggeration, I asked her to save the discharge of the next 
day, that I might see it. This she did, and I am sure that it 
was as much as I could hold in my two hands. I put her on 
the examining table, and in a good light inspected the rectum 
through a long speculum. ~No evidence of disease could be 
found there. There was no special pain anywhere, and but 
little sensitiveness over the sigmoid flexure or descending 
colon ; no history of former acute trouble, but for many years 
she had been of a decidedly constipated habit. I had her 
take an aperient, and the same day to wash out the bowel by 
enema, when I explored the sigmoid flexure with a JSTo. 8 
Wales bougie attached to a Davidson syringe. I commenced 
the exploration by gradually inserting the instrument and 
throwing a small quantity of warm water before it. It passed 
easily into the sigmoid, and the patient then complained of 
pain at that point, showing an evident sensitiveness there. I 
could not detect that there was any impaction of faeces, but, 
when I withdrew the bougie, the point for several inches was 
covered with a "viscid, glairy mucus" containing pus. Sat- 
isfied that I had found the seat of trouble, and that it was an 
ulceration, I began the treatment by washing out the flexure 
with a large quantity of hot water, thrown into it by means 
of the bougie. Each alternate day thereafter I injected the 
sigmoid with the following : 

9 Fluid hydrastis 3 j ; 

Aquse dest § j. M. 

This was deposited and allowed to remain. After treating 



DISEASE IN THE SIGMOID FLEXURE. 431 

many cases of the kind, I am persuaded that the fluid hydras- 
tis is the best agent that can be employed. It is non-irritat- 
ing, does not pain in the least, can be retained without effort, 
and is an admirable astringent. It should be seen that the 
fluid, and not the fluid extract, is obtained, for the latter is 
very irritating on account of the alcohol it contains. This 
patient was treated in this manner for several months, the 
only difference being that the intervals for injecting were 
prolonged. She was entirely cured, all the discharge and 
pain disappearing. 

Case II. — A gentleman was sent to me for treatment from 
Galveston, Texas, by a former patient. He was in middle life, 
and expressed himself as being a great sufferer from rectal 
disease. As he gave me a history of his case I asked a num- 
ber of questions, and elicited the following : About three 
years back he first noticed that, whenever he had a call of 
Nature, he experienced severe pain in his left side before his 
bowels acted. Upon asking him to locate his pain by touch, 
he put his hand over the region of the sigmoid flexure. At 
that time he had no special diarrhoea, had had slight attacks 
of it, but regarded himself of the constipated habit. This pain 
increased as time went on, and he had a dysenteric discharge 
established. His disease had been diagnosticated as a chronic 
dysentery by several physicians. He had lost flesh and took 
very little interest in his business ; was of a bad color, and 
melancholy. His rectum was submitted to a rigid examina- 
tion, but I was unable to detect any special trouble there. 
True, the upper part appeared slightly congested, but I may 
have been mistaken even in this. A No. 8 Wales rectal bougie 
was passed into the flexure without difficulty, although he 
complained of pain in the "left side "when the instrument 
entered the sigmoid. Upon the point of the bougie, when 
withdrawn, was a glairy mucus. His habit was to go to 
stool eight or ten times in twenty-four hours. I could not 
make out any tumor by palpation. An examination of his 
discharges revealed a coffee-ground appearance of faeces, a 
few clots of blood, and much mucus. I thought that I de- 



432 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

tected the " peculiar odor" of cancer. Anyway, I wrote to 
his friends that I suspected malignant trouble in this case, 
and believed it located in the sigmoid flexure. One point I 
wish to speak of here is, that it will be noticed that I say a 
No. 8 rectal bougie passed into the flexure without difficulty. 
Stricture is sometimes found at the entrance of the flexure ; 
cancer is located above it ; but in many cases I have known the 
growth to be in the upper part of the flexure, and if contrac- 
tion existed, it was higher up the colon. A second point : I 
have never been a believer in spasmodic strictures of the gut. 
There could be no better place to find one than at the entrance 
of the sigmoid, where there is a certain aggregation of mus- 
cular fibers. Third : If, as has been imagined by some, a third 
sphincter muscle exists at this part of the rectum, this would 
have been a most excellent time for it to have shown itself. 

This patient remained with me for two weeks, and I in- 
jected the sigmoid daily with the fluid extract of Pinus cana- 
densis, alternating with the following mixture : 

9 Sweet-almond oil O j ; 

Subnit. bismuth. 5 ij ; 

Iodoform 3 j. 

M. Sig. : Shake well each time before using, and inject 
one ounce at bed- time, through a Wales bougie. 

The Pinus canadensis is diluted with four to six parts 
of water. It requires some expertness in injecting the oil. 
My method is to introduce first the bougie into the rectum 
for four inches, then, pushing the small point of a Davidson 
syringe into it, into which the hot water is already drawn, I 
throw one bulbful through the instrument, and by the aid of 
the water the bougie will pass easily into the sigmoid. Then 
drop the suction end of the syringe into a cup containing 
the oil preparation, draw into the bulb the amount that you 
wish to inject — generally one ounce — and, having injected it, 
drop the end of the syringe back into the pan of hot water 
and throw one additional syringeful behind the oil, which 
forces it well into the sigmoid. By this procedure we throw 
two bulbfuls of water and one of the preparation into the 



DISEASE IN THE SIGMOID FLEXURE. 433 

part intended. It will be retained sometimes for one hour, 
sometimes indefinitely. At the end of two weeks the num- 
ber of evacuations had been reduced in this man from eight 
or ten to two or three per day. He left for home after I had 
given full instructions how to use the bougie, and had 
seen that he could do it without harm. I received several 
letters from him, but after a while they ceased, and I sup- 
posed he was dead, or nearly so. I afterward learned that 
he had entirely recovered. My diagnosis was incorrect, but 
I had the pleasure of knowing that my treatment was 
good. 

Case III. — Miss B. L., aged twenty-one years, had been 
in most excellent health all her life until about one year past, 
when a painful dysenteric (?) discharge began. She would 
go often to stool and pass a muco-purulent or muco-bloody 
action, sometimes only clots of blood. She had lost much 
flesh when I saw her, and was not able to walk alone. She 
would recline often on a couch, and then be assisted to bed. 
She complained of intense pain in the back and often in the 
abdomen. Several times a large quantity of mucus passed in 
the bed, she being unable to control it. Although I passed 
several long tubular speculums into the rectum, the examina- 
tion did not reveal enough trouble to account for her symp- 
toms. No tumor could be defined anywhere. To help me in 
my diagnosis, I had specimens submitted to a microscopist, 
and he pronounced the discharge malignant. I began the 
injection of the sigmoid flexure with fluid hydrastis, half an 
ounce to four ounces of water, through a Wales bougie, 
depositing it in the flexure. I would alternate it weekly 
with the use of the oil, bismuth, and iodoform. The symp- 
toms began gradually to disappear, and after two months 
had all subsided. She is now entirely well. 

Case IY. — Dr. R., an eminent physician and surgeon, of 
New Orleans, consulted me a short time ago in reference to 
himself. He had lost some flesh and was of a bad color; 
complained of pain in the left inguinal region, for which he 
was in the habit of taking an opiate. He suffered from a 

28 



434 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

decided obstipation of the bowels — so much so that he had to 
resort to frequent injections of hot water to coax the faecal 
mass down from the sigmoid flexure ; and then, after it had 
fallen into the rectum, he experienced great difficulty in get- 
ting it to evacuate. The action was usually hard bits of fse- 
ces, and caused a straining effort at stool. I examined the 
rectum carefully, and outside of a large, capacious pouch, it 
was normal. Introducing a Wales bougie, by the aid of hot 
water injected before it, no difficulty or obstruction was de- 
tected until the entrance of the sigmoid flexure was reached, 
when it refused to go any farther. Although I tried dili- 
gently, it could not be passed into the flexure. I believed, 
and so expressed to him, that a stricture existed at that 
point. He being a surgeon of rare ability, I advised him to 
get a smaller bougie, take it home with him, and by persever- 
ance I thought that he would eventually succeed in getting it 
into the flexure. When this had been accomplished, I pre- 
scribed the use of the almond oil, subnitrate of bismuth, and 
iodoform mixture, and occasionally to inject with the diluted 
hydrastis. He wrote me several weeks after his return home 
that he had succeeded in introducing the bougie into the flex- 
ure, and that he felt improved from the treatment. I am 
unable to decide definitely in my mind what the character 
of growth was that was producing this obstruction at the 
entrance of the flexure, but I am suspicious of its nature. 
The case bears out, however, what I have said — viz. : that 
it is a most difficult matter to define a growth in this part 
of the colon, and a more difficult one to tell the nature 
of it. 

Another case which beautifully illustrates the good results 
that can be obtained from medicating the sigmoid flexure is 
the following : 

Case V.— General M. was brought to me for treatment by 
his family physician. Although a man of corpulent form, 
he had lost much flesh. His color remained good. He had 
complained for months of pain in the left inguinal region, 
accompanied with frequent attacks of " haemorrhage." The 



DISEASE IN THE SIGMOID FLEXURE. 435 

idea conveyed was that for an interim blood would not pass 
from the rectum, but suddenly upon going to stool, a large 
quantity would pass, and as many as from seven to ten actions 
would take place in twenty -four hours. Malignant disease 
had been suspected by his attending physician. Upon exami- 
nation, no tumor could be detected over the sigmoid, and no 
disease in the rectum. Believing the trouble to be in the 
sigmoid flexure, I asked him to remain at the infirmary, 
where he could be properly treated, to which he consented, 
when the injection of the oil preparation named was begun. 
He was kept most of the time in the recumbent position, and 
the medicine was deposited in the colon once a day. I should 
remark that upon the day of his arrival he had seven large 
haemorrhages from the bowels ; a few were pure blood, the 
others were mixed with mucus. After the first injection the 
amount of blood and mucus began to diminish, and in a 
week's time they had disappeared. He expressed himself as 
feeling much relieved, and was allowed to sit up as much as 
one half the day. During the time of treatment I did not 
restrict his diet. In the majority of cases I do so, however. 
After two weeks' stay at the infirmary he left for home, where 
his physician kept up the treatment, substituting the fluid 
hydrastis, after two weeks, for the oil preparation. At the 
end of a month I received a note from the doctor, which said : 
" The treatment with hydrastis was kept up twice a day for 
a week. There is no mucus in the discharges, and no blood. 
His bowels move but once in twenty-four hours ; he is com- 
ing to town every morning to his office, and is now attending 
his court. He is much better, and is feeling and looking 
splendidly." 

Case VI. — In May, 1890, I received a dispatch from a 
physician to come to Shelby ville, Ind., to see a patient suffer- 
ing from some form of rectal obstruction. I went over in the 
afternoon, and was met at the station by the patient, who 
was driving his carriage. He was a man about fifty years of 
age, and to all appearances was the perfect picture of health. 
He was a short, well-built man, of ruddy complexion, and in 



436 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

good flesh. After reaching the house he told me the follow^ 
ing: "Several years ago I began to suffer with attacks of 
pain in my left side. At first they were not severe, but as 
time went on they increased in severity, until now they are 
past endurance. I am thoroughly constipated, and can not 
have an action without the greatest difficulty ; and then it is 
not satisfactory, because only small bits pass — never a free, 
well-molded action. I often go to stool, and pass only mucus, 
or mucus and blood." 

His appetite was fairly good, and, as I have said, he 
looked like a healthy man. I stripped him and had him lie 
down on a hard table. Over the region of the sigmoid flex- 
ure I detected a well-formed tumor, which I at first thought 
was just under the skin, but by manipulation I could feel 
that it had a deeper base. I was then told that this tumor 
was congenital and had never given him any trouble. I then 
searched the rectum with the fingers and with the speculum, 
but could detect no trouble there. I gave it as my opinion 
that a tumor of some kind was embracing the sigmoid flex- 
ure, and was causing an obstruction, and, although an oper- 
ation was not justifiable at that time, the time would come 
when it would be the best to do a colotomy, and in that 
event they could telegraph me. I did not think at this visit 
that the offending tumor was cancer, especially because the 
man's looks did not indicate it. He was in good flesh and 
had a fine color. I was informed, after my examination of 
him that Dr. Cook had seen him a short time before and 
gave very much the same opinion as myself, except that he 
believed that the tumor was a malignant one, and had no 
connection with the congenital one. Some time after I saw 
him he was taken to see a distinguished surgeon in Chicago, 
who, so I am informed, gave it as his opinion, after a rigid 
and painful examination, that there was really nothing of any 
concern the matter with the patient. He was advised to go 
home, attend to his daily business, and "forget himself." 
This encouraged his friends, but the man gradually went 
from bad to worse, until he died a few months afterward. 



DISEASE IN THE SIGMOID FLEXURE. 437 

An autopsy revealed a large malignant tumor, which had 
blocked the sigmoid and constricted its entrance, and death 
resulted from perforation. 

Case VII. — This case will show how a certain article of 
diet can cause an unsuspected impaction of the sigmoid flex- 
ure. Dr. W., over seventy years of age, had been constipated 
for some time, and conceived the idea that a diet of oatmeal 
exclusively would overcome it. Consequently he adopted the 
plan, and lived only on this article for three weeks. About 
that time he became aware that his bowels were not moving 
at all. He tried purgatives, but without effect. His condi- 
tion became alarming, and he called his physician. Numer- 
ous plans were tried to produce an evacuation, but all failed. 
Several physicians were called, and each recognized that there 
was an obstruction somewhere in the bowel. At last perito- 
nitis began to develop. His physicians had tried to introduce 
a rubber tube, a stomach tube, a Wales bougie, etc., into the 
sigmoid flexure, but it could not be accomplished. About 
this time I was called in consultation. The case was described 
to me by his physician, and I was asked to go to him and try 
to introduce the bougie and to report my diagnosis. Accom- 
panied by one of the attending surgeons, I went to his room 
and carefully examined him. His temperature was high and 
pulse rapid. He was, however, able to give me a lucid de 
scription of his case. I then anointed a Wales bougie, which 
was attached to a Davidson syringe, and, gently inserting it 
into the rectum, I firmly pressed it up until I was satisfied 
that it had reached the entrance of the sigmoid. Water was 
then forced through the tube, and after a little while the in- 
strument passed fully one inch farther, but seemed to be en- 
gaged at this point, and would go no farther. Withdrawing it, 
we found the end of it loaded with fsecal matter which looked 
like soft white or yellow clay—evidently faeces made by the oat- 
meal diet. Upon my return to the physicians, I gave it as my 
opinion that it was a case of impaction of the sigmoid flexure, 
caused in the manner just indicated. We all agreed that 
the sigmoid was the seat of trouble, and attempts were made 



438 DISEASES OF THE KECTUM, ANUS, AND SIGMOID FLEXURE. 

daily to wash it away, but without success, the man dying 
shortly after. 

I have recited a sufficient number of cases to show that the 
sigmoid is a common seat of disease, and to emphasize one 
point especially — that it is a difficult thing to make out a tu- 
mor at this locality, be it malignant, non-malignant, or an 
impaction. 

The flexure may be affected with the following pathologi- 
cal conditions : 1. Congestion. 2. Inflammation. 3. Simple 
ulceration. 4. Specific ulceration (syphilis). 5. Malignant 
ulceration or growths. 6. Stricture (either malignant or non- 
malignant). 7. The receptacle of foreign bodies causing dis- 
ease. 8. Tuberculous ulceration. 

1. Congestion. — I make a distinction here between a con- 
gestion and an inflammation, from a pathological standpoint, 
because I believe if the congested condition is recognized, it 
can be cured before any changes constituting the phenomena 
of inflammation take place. I am satisfied that many of the 
so-called catarrhal conditions of the bowels are simply cases 
of a local congestion in the sigmoid, having their discharge of 
mucus — not pus— and evidencing such symptoms as pain in 
the abdomen and some reflected symptoms. A number of 
such have been cleared up in my practice by washing out the 
alimentary canal by aperients, and by a local washing of the 
sigmoid flexure with large quantities of hot water alone ; or, 
if any medicament was used, the fluid hydrastis in full dilu- 
tion is found of great service. I have seen patients discharge 
as much as six ounces of mucus a day from causes like this. 
But when it is remembered that the slightest irritation of the 
mucous membrane will cause its rapid secretion, it is no won- 
der. It is wonderful how quickly these cases clear up with 
the proper treatment. 

2. Inflammation.— After the inflammatory changes have 
taken place in the gut, it is a difficult thing to effect a cure. 
The symptoms are aggravated, and some of these cases are 
very obstinate and resist treatment for a long time. The same 
plan is to be pursued, with the addition, however, of a re- 



DISEASE IN THE SIGMOID FLEXURE. 439 

stricted diet. Whenever simple inflammation attacks the 
sigmoid flexure, it is accompanied with many reflex symp- 
toms, such as pain in the back, colicky pains in the stomach 
and bowels, often a localized pain over the left inguinal re- 
gion, a great amount of flatus, diarrhoea, sometimes constipa- 
tion, straining at stool, although the most pain is before going 
to stool, caused by the faeces passing through the sigmoid 
flexure. The discharges sometimes assume a dysenteric char- 
acter, though they are not so apt to as when the flexure is 
the seat of ulceration. These patients often count themselves 
invalids without knowing their real trouble, and with all def- 
erence I would say that they are often mistaken for other 
troubles by the physician, and the disease treated by medi- 
cines in a general way, when local treatment is indicated. I 
am firmly convinced that constipation is the most frequent 
cause of inflammation in the flexure. This is a natural con- 
clusion, when we take into consideration the physiology of 
the act of defecation. The fsecal mass being lifted back from 
the rectum to the sigmoid flexure, deprived of its water, lies 
there in a dried condition, acting as an irritant and causing 
at first a congestion of the blood-vessels, which goes on to 
inflammation, and ends in an ulceration of the mucous mem- 
brane. Constipation being first the cause, the order of things 
is now reversed, and the condition causes constipation. In 
such condition, then, many patients are given a purgative 
course of treatment, which is adding fuel to the flame. Under 
these circumstances a local application to the flexure of the 
almond oil, bismuth, and iodoform is most grateful. But 
these patients should be kept under a strict surveillance and 
guarded in diet, exercise, habits, etc. It would be much bet- 
ter, if we looked to a speedy recovery, if they were confined 
to the bed or their room during the treatment. 

3. Simple Ulceration. — This is a much more serious con- 
dition than either of the other two, although it may be re- 
garded as a third stage of the same disease. Just as sure 
as congestion will end in inflammation if stasis occurs in the 
blood-vessels, just so sure will inflammation end in ulceration 



\ 



440 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

of the gut if the inflammatory deposit remains, and if the gut 
is subjected to friction by the passage of the faecal mass or 
irritation by pressure. In the ratio of its being the third 
stage in the inflammatory disease, it is three times more seri- 
ous in its nature than the first step — congestion. Although 
in the beginning the reflexes were mild, they are now deter- 
mined ; the pain was slight, it is now severe ; the discharge 
was mucous, it is now muco-purulent and bloody ; the ac- 
tions, then infrequent, are now frequent. Even in the second 
stage the patient was able to go around and suffered an im- 
munity from any exhausting symptoms ; with ulceration, 
every action reduces the patient nearly to utter exhaustion. 
There is great straining at stool and the bowel never feels 
emptied ; an uneasiness is felt always in the abdomen ; the 
reflexes extend to the womb, ovaries, tubes, etc., in the fe- 
male, and to the bladder, urethra, and prostate in the male. 
The patient suspects and the doctor often believes that ma- 
lignant disease exists somewhere, and the treatment given is 
usually of a palliative character, not curative. He drifts 
from bad to worse, and after a while is a confirmed invalid. 
May it not be for want of proper treatment? Many cases 
of diarrhoea or dysentery (?) I am certain would find an 
explanation if the sigmoid flexure was searched. Indeed, I 
have treated many cases and carried them to a full convales- 
cence that had "gone the rounds" for chronic diarrhoea or 
dysentery. In all such cases I would suggest that the flexure 
be explored and treated, and many will clear up. The manner 
of treatment is the same, in a general way, as that of simple 
inflammation of the gut, with the addition of a stimulating 
injection first. One of the best is a weak solution of nitrate 
of silver, say five grains to an ounce of water, deposited in 
the flexure, and afterward followed with injections of fluid 
hydrastis or Pinus canadensis, diluted four parts with 
water, and then the use of the oil preparation as already 
prescribed. 

Specific Ulceration. — What I have said, so far as symp- 
toms, etc., are concerned, in simple ulceration of the flexure, 



DISEASE OF THE SIGMOID FLEXURE. 441 

obtains in cases of specific ulceration or ulceration the result 
of syphilis. That the sigmoid is often the seat of such ulcera- 
tion I am convinced ; and that it is equally overlooked I am 
satisfied. In a local way it would present very much the 
same line of symptoms as simple ulceration, but, in addition, 
we would either have a history, or likely find evidence, of 
secondary syphilis. I say likely, for the reason that I mean 
to imply a doubt, for I have seen cases of undoubted syphilitic 
ulceration of the rectum and sigmoid flexure where no other 
evidences of constitutional affection existed. In addition, 
therefore, to a local treatment in cases where we have cause to 
suspect syphilis, we are to employ a constitutional as well as 
a local treatment. 

We have quoted Cruveilhier as saying that the mucous 
membrane of the large intestine and the stomach are very 
much alike in an anatomical way, and have already given his 
comparison. Every physician is aware of the fact that a 
gastric ulcer has a decided tendency to extend in depth, and 
ultimately it may perforate the wall of the stomach. Leube, 
in referring to this fact, says, in his admirable article in 
Ziemssen's Cyclopaedia : " When perforation does take place, 
it would almost always be followed by a general fatal peri- 
tonitis, were it not that, fortunately, in about forty per cent 
of the cases, this result is obviated or at least delayed by ad- 
hesions between the stomach and the neighboring parts. In 
this way the stomach at the point of ulceration becomes glued 
to the pancreas, spleen, liver, etc." 

Now, in contrast to this, we have demonstrated that the 
sigmoid flexure hangs down in the pelvis like a bag, and has 
no fixed position at all, and yet it is subject to ulceration 
just as often, and perhaps oftener, than the stomach, and the 
ulceration evidently has also a tendency to extend in depth ; 
consequently perforation of the wall of the colon is likely to 
occur, and, if such result takes place, a fatal peritonitis 
would occur, because there are no fixed adhesions usually in 
this condition of affairs of the sigmoid flexure. I have cited 
two cases in former chapters in this book where I am sure 



442 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

that death was the result from perforation because of this 
ulcerated condition in the sigmoid. 

Of course, in dealing with disease in the sigmoid flexure, 
we must of necessity include the remainder of the descending 
colon at least, and, in order to emphasize my conclusions, I 
desire for a time to speak more especially of the large intes- 
tines. The long axis of the large intestine intersects that of 
the small intestine at almost a right angle. I have already 
indicated that the three points of accumulation of faeces, and 
consequently of disease, are the caecum, sigmoid flexure, and 
rectum. The caecum is inclosed by a serous layer, and below 
it we find the appendix vermiform is. How often this is the 
seat of disease requiring medical or surgical treatment every 
physician is aware, and it is not my province to deal with it 
here. The colon has a horseshoe shape, and hence has been 
divided into three parts. Because of this peculiar bend, we 
have both to the right and to the left a distinct flexure. At 
the flexures, it is well known that the passage of ingesta 
meets with delay. It is said that this explains the fact that 
in inflammatory processes, particularly dysentery, the chief 
foci of disease are found at the flexures, and also shows the 
advisability of giving special attention to these places by per- 
cussion and palpation in cases of constipation. Now, if this 
is true— and of its truth no one can doubt — the reasons for 
detecting accumulations in the sigmoid flexure are especially 
apparent. We have tried to demonstrate that this is the 
seat for impaction of faeces, and not the rectum, as is gen- 
erally supposed. And yet I have asserted that it is often 
impossible to detect . this accumulation in the sigmoid by 
palpation, and I also differ from those who say that it can 
be detected by percussion. "The dull note to the left of 
the spine just above the crest of the ilium" is not often 
present. It is very well, under this head, to deal with the 
anatomy of the part a little more minutely, that we may un- 
derstand its pathology. Not only is the mucous membrane 
of the large intestine very much like that of the stomach, but 
the minute distribution of the blood-vessels in the large intes- 



DISEASE IN THE SIGMOID FLEXURE. 443 

tine is also similar to that which is found in the gastric mu- 
cous membrane. The arterial supply of the large intestine is 
derived from the superior and inferior mesenteric arteries, the 
latter of which gives off the superior hemorrhoidal to the sig- 
moid flexure and the posterior wall of the rectum. The su- 
perior hemorrhoidal communicates with the middle hemor- 
rhoidal derived from the hypogastric, and with the inferior 
hemorrhoidals from the common pudendal. The veins corre- 
spond, in course and name, to the arteries mentioned ; thus 
the veins of the colon empty into the superior and inferior 
mesenteric. It is not necessary to speak just here of the 
blood-supply of the rectum, for its anatomy has been con- 
sidered in another chapter. The nerve supply of the colon 
has already been referred to. 

We have spoken of the power that the colon has of ab- 
sorbing water, and have referred to the fact that as much as 
a gallon can be thrown into it and retained, going rapidly 
into the circulation and being eventually thrown off by the 
kidneys, etc. The probability that the large intestine plays 
a more important part in the absorbent process than is com- 
monly supposed, is supported also by the fact that in dogs 
with a fistula of the colon, the food escapes through the 
opening as early as an hour and a half after food is taken, 
while, as is well known, the food usually tarries in the large 
intestine for at least twenty times this period. So we see 
that the colon is made to do not only its own function, but is 
also called upon to perform the functions of the stomach ; 
therefore we have a double reason for supposing that it is 
frequently the seat of trouble, such as congestion, inflamma- 
tion, ulceration, etc. I have spoken in this article of medi- 
cating the sigmoid with an oil. Now, it has been demon- 
strated that the large intestine under certain circumstances 
is able to absorb fat. The oil preparation to which I have 
referred as being a favorite of mine for such treatment is 
generally retained, and consequently absorbed. A very nice 
point here is the application of these results to the practice of 
feeding per rectum, or per colon, by enemata. It is also well 



444 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

known that the peristalsis in the small intestine is very active 
and rapid, and propels its contents quickly into the large in- 
testine. In the colon the opposite of this is true, the peristal- 
sis taking place very slowly. Hence the very long delay of 
the fseces in the colon, more especially in the sigmoid flexure. 
We have had frequent occasion to speak of the so-called 
catarrh of the intestines. Now, in many cases where this con- 
dition was referred to the small intestine, I satisfied myself 
that the condition existed only in the colon, and have evi- 
denced that fact in the citation of cases in this chapter. 

This condition I shall only speak of as being a chronic 
one or brought about by long-continued causes. Therefore, 
where the intestinal mucous membrane in acute catarrh is 
characterized by a vivid scarlet complexion, in a chronic con- 
gestion of the mucous membrane of the sigmoid flexure we 
would have a bluish or dark complexion. Sometimes there 
would be extravasation of blood, sometimes not; but that 
the inflammatory exudation is very decided there is no 
doubt, and this accounts for the great amount of mucus 
which is sometimes poured out ; and when the ulcerative 
process has taken place, we have the purulent exudation to- 
gether with the swelling of the mucous membrane. Now, it 
is a noticeable fact that in the large intestine, especially dur- 
ing a chronic intestinal catarrh, its mucous membrane pro- 
liferates in various places in the form of capillary tumors ; 
therefore it can be easily seen that the pathological condition 
here in the large intestine — say, of the sigmoid flexure — is very 
decided both in the mucous membrane and in the submucosa. 
No wonder, then, that the morbid process rapidly advances, 
and the degeneration of coats takes place. I do not think it 
can be doubted that the colon js the most frequent seat of 
catarrh, or, more properly speaking, of that condition which 
excites to catarrh. There is but one reason for this, and that 
is that the walls of the colon are exposed to the friction of the 
passing or retained faecal mass. Physiology teaches us that 
the fseces begin putrefaction while in the colon, and also that 
septic organisms cling readily to an inflamed mucous mem- 



DISEASE IN THE SIGMOID FLEXURE. 445 

brane. I think the dark color, emaciation, sweats, etc., that 
are frequently observed in persons suffering from the consti- 
pated habit are all due to a species of sepsis, or so-called 
blood-poison ; at least it is a fact that, while the f aeces are 
held in the sigmoid flexure, the water constituent has been 
absorbed and passed into the circulation. Now, when we 
consider that the putrefactive changes were going on, or had 
taken place in this mass, we can very well understand how it 
is that the septic organisms can be passed through the blood. 
I hold that the sigmoid flexure is more responsible for the 
confirmed habit of constipation, with all of its incident 
troubles, than any other portion of the alimentary canal, and 
I imagine that if the aesthetic young lady could come to real- 
ize the fact that she is daily absorbing into her system the 
putrefied faecal mass, she would pay more attention to the 
physiology of defecation than she does, and yet, if she con- 
sults her physician, she is often pacified by the statement 
that her trouble amounts to nothing, and her only need is in 
an active purgative pill. This was among the first things 
that actuated me to investigate the sigmoid in disease. 

If inflammation attacks the caecum, the common term to 
indicate the condition is typhlitis, and I will not moot the 
question with those gentlemen who so strongly maintain that 
the appendix vermiformis is the seat of trouble in such 
cases ; but I simply mention the fact that typhlitis is un- 
doubtedly sometimes produced by faecal impaction. We 
know that if the faeces are retained in the caecum and are 
not removed, inflammation will take place, which results in 
an ulceration, and this will lead to perforation, which ordi- 
narily means death. I will incidentally remark that I am 
a believer in the doctrine that the appendix vermiformis is 
perhaps more commonly the seat of inflammation than the 
caecum, and that whenever it is the case has passed out of 
the hands of the physician and should belong to the surgeon. 
When inflammation attacks the colon or rectum, it is called, 
respectively, colitis or proctitis. I have already considered 
the changes that take place in the colon from inflammation, 



446 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and proctitis will be considered under the head of inflamma- 
tion of the rectum. I do not wish to enter into any discus- 
sion as to what causes inflammation of the mucous membrane 
of the intestinal tract, save of that part of it which is in- 
cluded in the sigmoid flexure and descending colon. It is 
an admitted fact, however, by all those that have studied the 
aetiology, that the intestinal mucous membrane is particu- 
larly liable to inflammation, and, as Leube says, even slight 
irritation may suffice to incite the inflammatory act. There- 
fore, to pass by the causes which excite to enteritis, I wish 
particularly to reafnm that any long- continued irritation of 
the mucous membrane of the intestines will surely excite to a 
consequent congestion, inflammation, and ulceration, and, if 
other portions of the intestine are liable to the inflammatory 
changes, the sigmoid flexure is more especially disposed to 
this condition. In the small intestine, undigested food, etc., 
may excite to the condition ; in the larger intestine it is more 
mechanical, and arises from direct irritation caused by for- 
eign bodies, hardened fseces, etc. Now, outside of this 
mechanical irritation, it is conceded by physiologists that 
there is a chemical action inducing to disease, brought about 
by the putrefactive changes in the faecal mass which is not 
allowed to pass. 

I have stated in my recital of cases that in inflammation 
of the sigmoid flexure diarrhoea was frequently a prominent 
symptom, and yet v literally speaking, this was not a diar- 
rhoea. The peristalsis was excited by the mechanical irrita- 
tion of the mass, and frequently when the patient yielded 
to this solicitation to go to stool only mucus, perhaps some 
blood, would be passed. What an error would be committed 
to treat this diarrhoea (?) by the astringent plan or by opium ! 
And yet I imagine it is sometimes done. Trae, the physician 
may order the usual aperient, but he also usually orders the 
opium afterward. How necessary it is to watch the subse- 
quent symptoms and treatment of such a course can be easily 
seen. When we are dealing with catarrh of the rectum it 
will be observed that the evacuations are very seldom liquid, 



DISEASE IN THE SIGMOID FLEXURE. 447 

but often consistent, which condition frequently throws us 
off our guard. No one would deny that the accumulation of 
hardened fseces in the rectum would produce proctitis, and 
yet many seem to forget that the same thing would cause an 
inflammation in the sigmoid flexure. Therefore, although 
diarrhoea, so called, is a symptom of disease in the sigmoid, 
it is not a necessary symptom, and, even when it does exist, 
the discharges should be examined and the character of them 
seen and not described by the patient. Whenever there is a 
chronic condition, exciting to a discharge of blood, of mucus, 
and of pus, some grave trouble must be looked for, and the 
seat of this trouble will be found either in the rectum or in 
the sigmoid flexure. In one of the cases that I reported I 
mentioned the fact that a lady patient passed as much as half 
a pint of mucus at an evacuation, and she would frequently 
have these evacuations. It is too often the case that if a large 
amount of mucus is passed, the physician refers it to the 
rectum. My experience has been that the location is most 
frequently in the colon. When the feces are discharged in a 
hardened condition, enveloped in mucus, I generally refer the 
trouble to either the sigmoid flexure or the rectum. De Costa 
says: u In rare cases, particularly in hysterical women, co- 
herent cylinders of mucus are discharged, in the form of 
membranous casts of the intestine, from an inch to a foot in 
length. Their discharge is accompanied by attacks of colicky 
pains (often above the umbilicus), distention of the abdomen, 
and an aggravation of the previously existing obstinate dys- 
pepsia." 

From the phraseology employed here, it is to be inferred 
that this condition of affairs occurs more especially in the 
hysterical woman ; ergo, the hysteria is partly if not wholly 
responsible for this condition. I certainly can not accept 
this proposition. Whenever I see " cylinders of mucus, 
from an inch to a foot in length," attended by " attacks of 
colicky pain, distention of the abdomen," etc., I am sure that 
I am dealing with a pathological change in the bowel with 
which hysteria has nothing to do. When inflammation ex- 



448 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

ists in the sigmoid flexure, the local pain elicited at that 
one point is not very definite, but the radiating pains by re- 
flex to the abdomen, back, thighs, bladder, etc., are very 
pronounced, and it is the aggregation of these symptoms, if 
I can so speak, that gives us an indication of the nature of 
the trouble ; and yet, where ulceration exists in the sigmoid, 
deep pressure over its site will elicit a response. 

Leube says : " Chronic catarrh of the rectum is charac- 
terized by an abundant discharge of pus, which sometimes 
oozes constantly from the anus, so that a simple inspection 
reveals the nature of the case." Now, whenever I see pus 
escaping from the rectum, I am satisfied that the disease has 
progressed further than the inflammatory state. As long as 
the mucous membrane is intact, I care not how much in- 
flamed it may be, there is not going to be abundant dis- 
charge of pus oozing constantly from the anus ; but it will 
be observed, upon a local inspection of the part, that a deep- 
seated ulceration exists. Therefore I think the term catarrh 
should be restricted to an inflammation of the mucous mem- 
brane of the intestine, where the discharge from such a 
condition is mucus, perhaps abundant, but not pus. When 
the colon is inflamed, the proper term is colitis ; but there 
should be a distinction drawn between inflammation per se 
and the ulcerative process, and no one symptom can so point 
out to us that distinction as the discharge. If it be mucus, it 
is catarrhal or inflammatory. If it be pus, it is from an ulcer- 
ated surface. If it is muco- purulent, then there is a coinci- 
dent inflammation and ulceration. I am very well aware of 
the fact that ulceration is set down as one of the results of 
the inflammatory act, but yet I say that, so far as the treat- 
ment is concerned, it is absolutely necessary to recognize 
the difference. We must consider the fact that if a chronic 
inflammation exists in the intestinal tract at any site, the 
danger is that a stricture will take place at that particular 
locality, and if a stricture results and the natural evacua- 
tion of the bowel is prevented, we are to apprehend serious 
trouble. Several years ago I reported a case of a stricture 



DISEASE IN THE SIGMOID FLEXURE. 449 

at the lower border of the sigmoid flexure caused by chronic 
inflammatory trouble (specific), and we all know how serious 
is this pathology of the gut. We have shown to what dan- 
gers the caecum is subjected by inflammation, and we may 
add the same condition in the appendix vermiformis — all 
caused by the inflammatory changes ; so we can argue that 
the sigmoid flexure, though of larger caliber, performs a dif- 
ferent function and is just as liable to disease, and that the 
consequent changes brought about by inflammation may, in 
the long run, prove just as serious. 

Treatment — I have already indicated the line of treatment 
to be pursued in inflammation of the sigmoid flexure. Mr. 
Hilton, in his most excellent book on Rest and Pain, has 
given us a great point in the treatment of disease. I do not 
know any class of troubles that calls so absolutely for rest 
as does that of inflammation ; therefore, when the colon or 
sigmoid flexure is inflamed, it should be rested. As a pre- 
paratory treatment, I have advised that the patient should be 
freely purged by the aperient plan. In conjunction with this, 
the sigmoid flexure should be washed out with large quanti- 
ties of hot water. It must be remembered that this can not 
be accomplished through the ordinary enema tube, but the 
very best instrument for the purpose is a Wales bougie of 
suitable size. Having cleared the alimentary tract, we are 
now to turn our attention to the diet of the patient, because 
this is one method of giving the colon rest. Any article of 
food which is difficult of digestion, or would cause a mechani- 
cal irritation in the bowel, must be prohibited. We do not 
desire much solidity given to the faecal mass, consequently 
we must avoid the use of bread and meat, and substitute as 
far as possible a liquid diet. Undoubtedly, milk is the best 
of all liquids to answer this purpose, but a milk diet alone is 
objectionable ; not enough consistence is given to the faeces, 
and chalky concretions are sometimes formed by its use and 
a constipated habit induced ; therefore, along with milk I 
advise the eating of very soft boiled eggs and the taking of 

some one of the prepared foods. Among the very best of this 
29 



450 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

latter class will be found the one manufactured by Reed & 
Carnrick, of New York. The preparation known as Bovinine 
answers the purpose admirably, in that it is very nutritious, 
and can be taken in either water, milk, or wine. I have 
found that these patients need a little stimulation, and, al- 
though whisky is usually contra-indicated in inflammatory 
troubles, I allow them to have a milk-punch occasionally. 
These patients should be confined to their bed in the recum- 
bent position. It must be admitted that it is practically 
impossible to render the organism aseptic by means of in- 
ternal antiseptics, or to make it in this way an unsuitable 
field for the growth of micro-organisms. Yet I am persuaded 
that the intestinal tract can be brought more or less under 
the influence of this class of remedies. Therefore, in affec- 
tions of the colon, I am in the habit of using such drugs as 
salol, bismuth, listerine, etc. The local form of treatment 
has already been indicated, and is as follows: The surgeon 
should be provided with a Wales rectal bougie, No. 5, and 
a good Davidson's syringe. After the sigmoid has been suffi- 
ciently washed out, the following mixture should be ordered : 

9- Sweet-almond oil O j ; 

Subnitrate of bismuth 5 ij ; 

Iodoform 3 i. 

M. Sig. : Shake well each time before using. 
The point of the syringe should be tightly fixed into the 
larger end of the bougie ; the bougie, well anointed with vase- 
line, should be pushed into the rectum about three or four 
inches, and then one syringeful of hot water thrown in front 
of it. It can then be passed into the sigmoid flexure. One 
bulbful of the oil preparation should now be drawn into the 
syringe and injected. An additional bulbful of hot water 
should now be drawn into the syringe and thrown behind the 
oil, thus pushing it all into the sigmoid flexure. The instru- 
ment is then to be withdrawn and the patient told to rest on 
the left side, the buttocks elevated. I have also advised that 
in cases of ulceration of the sigmoid this preparation should 
be alternated with fluid hydrastis, from two drachms to half 



DISEASE IN THE SIGMOID FLEXUliE. 451 

an ounce, diluted in half a cupful of hot water, and thrown 
into the sigmoid flexure by means of the bougie. If the 
ulceration be due to syphilis, of course the patient should be 
put under antisyphilitic medication. 

Cancer. — That the sigmoid flexure is frequently the seat of 
cancer there can be no doubt, and being inclined to the view 
that cancer begins as a local disease, we can with much force 
argue that traumatism is easily set up in the flexure ; but I 
know no portion of the body wherein it is as difficult to de- 
tect a morbid growth as in this one locality. I have already 
said that I do not believe that cancer of the sigmoid flexure 
can be detected by palpation. This rule will certainly hold 
good where we have a large abdomen to deal with. Possibly, 
where the subject is thin and emaciated, some obstruction 
may be evidenced at this point through the walls of the ab- 
domen ; but it would be a very difficult thing for a surgeon to 
say, outside of a clinical history of a case, what that charac- 
ter of obstruction was ; and, indeed, even in these cases where 
the abdominal walls are thin and flaccid, it would be the 
rarest case where the tumor could be defined. 

Symptoms. — The symptoms that attend incipient cancer in 
the sigmoid flexure are very much like those of a simple in- 
flammation, or perhaps an ulceration. So perfectly nil are 
the symptoms of a cancer in the colon that, in a number of 
cases that I have met, the patient has been suddenly attacked 
by what was supposed to be an acute obstruction of the 
bowel. In one of the cases already reported in a former 
chapter, I related the fact that a man had a complete obstruc- 
tion somewhere in the intestinal tract, which was difficult to 
locate, and when I introduced my hand into the rectum and 
pushed my fingers up to the sigmoid flexure, I found that it 
was one cancerous mass, producing a total obstruction of the 
bowel. And yet this man had not emaciated in the least, 
weighing at that time over two hundred pounds, which was 
his usual weight. It is a common rule that we never see 
these patients until a grave pathological condition exists, and 
even then they are simply complaining of reflex symptom s$ 



452 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and generally of constipation. In questioning these patients, 
it will be found that they have sometimes suffered with 
diarrhoea, alternating with constipation. They themselves 
may be deceived as to the state of the bowels in regard to 
evacuation, for patients are very apt to think that if they go 
to stool and have a passage, it matters not how small or of 
what consistence, the bowel has been emptied ; therefore, un- 
less you are very careful to trace the condition by more per- 
tinent questions, you will fail to elicit the true state of the 
case. I have already referred to the fact that pain in these 
cases is not a correct guide in forming an estimate of the 
gravity of the trouble. It is the common opinion among the 
masses that all cancers are extremely painful, and many of 
the profession drop into this way of thinking, and yet, on 
questioning these patients, oftentimes they will give you no 
history of any definite pain. By practicing percussion over 
the sigmoid, it will sometimes be evidenced by tenderness that 
some trouble exists there. I am in the habit, in making 
out a diagnosis in these cases, to have the patient suddenly 
flex his left thigh upon his abdomen. This generally causes 
him to speak of pain in the sigmoid. But a symptom of 
more regularity than this is the irregular action of the bowel, 
and this point should be definitely settled by the physician. 
He should also examine the character of the stool in refer- 
ence to three points : First, whether there is blood, mucus, 
or pus ; second, whether there is any consistence ; third, 
whether there is any molded condition. It will be found 
upon inquiry that there is an accumulation of gas in the ab- 
domen, evidenced by tympanic condition, and sometimes this 
accumulation of gas causes a colicky pain. I have also said 
in a preceding chapter that I do not put much stress upon the 
cachexia incident to cancer. If a patient is observed who has 
suffered a great haemorrhage, or who suffers from a small 
haemorrhage occurring often, it will be seen that this same 
peculiar color exists ; or, if a patient has a cirrhosed liver, he 
will take on this peculiar color. It is well known that or- 
ganic kidney disease will produce this muddy complexion ; 



DISEASE IN THE SIGMOID FLEXURE. 453 

therefore it can not be said that it is pathognomonic. There 
are many other conditions which will induce it. As intesti- 
nal stenosis takes place, we are apt to have more pronounced 
symptoms, such as distention of the abdomen, vomiting, 
etc. The peristaltic motion of the bowel is excited by the 
accumulation of the mass of faeces above the point of con- 
striction. It also excites to an antiperistaltic movement, and 
cancer located in the colon, especially in the caecum, excites 
to stercoraceous vomiting. A point of considerable impor- 
tance is the distention of the pouch of the rectum in the cases 
where the obstruction exists in the sigmoid flexure. By in- 
serting the finger it will be noticed that it can be swept 
around in a great space. It is possible that a small portion 
of the mass may be passed with the stool, and if saved by the 
patient the physician is enabled to form a more correct 
opinion. Wunderlich reports a case where one of his patients 
passed a cancerous mass as large as a walnut. Should this 
take place, it is very apt to be accompanied by an excessive 
haemorrhage. A diagnosis can be made between cancer lo- 
cated in the sigmoid flexure and cancer of the rectum by 
simply introducing the finger into the rectum and detecting 
the growth, and the train of symptoms is not so insidious 
when it is located lower down. When cancer of the rectum 
exists and involves the sphincter muscles, great pain is experi- 
enced, which is increased by walking, standing, or sitting, and 
it is also increased during the act of defecation. There is a 
greater disposition, too, to strain at stool, and generally, after 
sufficient length of time, the adjoining organs are implicated ; 
and yet physicians are frequently misled by the statements 
made by the patient, because examination externally reveals 
nothing either in cases of cancer of the rectum or of the sig- 
moid flexure. In making out a diagnosis of cancer in this 
locality, it must be remembered that an impaction of faeces in 
the flexure will give symptoms very much ]ike those of ma- 
lignant trouble. Even admitting that the tumor can be felt 
in the line of the colon, we must determine, if possible, 
whether it be carcinoma or simple impaction. It is believed 



454 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

by many that the diagnosis in these cases can be cleared up 
by the persistent use of irrigations and cathartics. This is a 
very good course to pursue, and yet we may be deceived in 
the matter of clearing up the diagnosis. I have already re- 
cited a case of an accumulation in the sigmoid flexure, super- 
induced by the eating of oatmeal, which terminated in death, 
notwithstanding that constant irrigation through a long tube 
was kept up and free purgation attempted. 

The distinction between a cancer of the transverse colon 
and cancer of the ascending colon, descending colon, or sig- 
moid flexure, can be drawn by the siight or complete immo- 
bility of the tumors in the latter. Now, to apply this point 
in the matter of diagnosis, it can be said that the sigmoid 
flexure would be the most movable, since this portion of the 
bowel has a long mesentery, and is, therefore, capable of 
being displaced, and yet there is no way of satisfying one's 
self upon this point except the introduction of the hand into 
the rectum and the feeling of the sigmoid by the fingers. , A 
method that is often practiced to determine at what point in 
the intestinal tract the carcinoma is located is to inject water 
into the bowel, and to notice the height to which it will go. 
It is argued that the less the amount of fluid that can be 
injected, and the more rapidly the water is discharged, the 
lower the site of the obstruction. If the growth be located 
in the sigmoid flexure, and the rectum be injected, it will be 
observed that just so soon as the walls of the rectum proper 
are distended the water will pass away; or, if a bougie or 
tube is used, there will be difficulty in getting it to enter the 
sigmoid because of the presence of the mass, and if water is 
thrown just as high as it can be got in this kind of case, it 
will immediately pass back. This might determine that there 
was an obstruction in the sigmoid, but it would be of little 
diagnostic value in telling us of what character the obstruc- 
tion was. 

Prognosis.— The prognosis in cancer of the sigmoid flexure 
is very bad. So far as its local treatment is concerned, scarce- 
ly any good can be accomplished save by washing the cavity 



DISEASE IN THE SIGMOID FLEXURE. 455 

out ; and yet this is dangerous, as the least force used might 
push the instrument through the peritonaeum. As in all 
cases of cancer, anything looking to its relief or cure must 
be referred to the surgeon. There are but two operative 
procedures for cancer in the sigmoid flexure : 1. Colotomy. 
2. Extirpation. 

In the chapter on cancer of the rectum I gave it as my 
opinion that colotomy was ill advised, save in exceptional 
cases. In cancer of the sigmoid flexure I would certainly 
double my objections. As we have demonstrated that there 
is no great pain accompanying the cancer at this seat, it would 
not be proper to open the colon until stenosis had taken place 
suflicient to obstruct the passage of fseces. Then the ques- 
tion is, Are we warranted in doing a colotomy as occlusion 
approaches, or when it becomes total % I recognize the fact 
that I am differing from many authorities who have written 
on this subject when I take a negative position. We have 
a cancer here located in a movable gut, with an early death 
facing us. Is it worth while to subject this unfortunate pa- 
tient to a colotomy who has but a few days to live \ If the 
obstruction is total, the question of an operation should be 
proposed not only to the patient but also to his family, with 
the disadvantages of it brought clearly to their minds. If 
for other reasons outside of a medical or surgical view there 
is a necessity of prolonging the patient's life, it may become 
unavoidable to do a colotomy. I think, however, this ques- 
tion should be settled by the patient rather than by his phy- 
sician. 

In determining between the two colotomies, where the can- 
cer is located in the sigmoid flexure, I am satisfied that the 
lumbar operation is the best, if for no other reason than that 
the opening into the colon would not include the disease, or 
be encroached upon by it. 

Extirpation. — The question often arises in the mind of the 
surgeon what operations are justifiable and what not justi- 
fiable. No surgeon should be guilty of doing an operation 
where he recognizes that no good can be accomplished by it ; 



456 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and in dealing with the subject of excising the sigmoid flex- 
ure for cancer, I would be almost inclined to class it as a piece 
of unjustifiable surgery were it not that several cases are re- 
ported where excision has been practiced successfully. The 
most notable case of the kind on record is the one reported 
by Dr. W. T. Bull, of New York. I wrote to the doctor to 
send me a reprint containing a description of this remarkable 
case, and I herein append his answer : 

"New York, January 7, 1892. 

"Dear Dr. Mathews : The case you refer to I can at 
present give you only an outline of from memory, for I 
have not the notes written up properly. A woman, aged 
fifty, on the fifth day of an acute intestinal obstruction was 
subjected to abdominal section, under the impression that 
the small intestine was compressed between the pelvis and 
a large fibroid tumor of the uterus. She was in extremis ', 
and vomiting fsecal matter. An annular stricture (cancerous 
by microscopical examination) was found ; an artificial anus 
was made by opening and securing to the skin in the middle 
line the large intestine just above the stricture. This was 
in March, 1886. She made a good recovery, but the carci- 
noma grew and projected out of the artificial opening and 
obstructed it. In January, 1887, the growth, including four 
inches of the sigmoid flexure, was excised. The ends, being 
too short for resection, were both brought out at the middle 
line. Prompt recovery and good functions of the new anus. 
I made an effort in November, 1889, to close up the anus by 
the aid of Dupuytren's enterotome, and by laparotomy and 
suture of the opening. This failed. Her general health con- 
tinued good, and the inspection of the abdomen showed no 
signs of the return of the cancer nor secondary deposits. In 
October, 1889, I succeeded by laparotomy in making an in- 
testinal anastomosis (Abbe's catgut rings), and in closing up 
the artificial opening entirely. She was in good health for 
the following two years ; then signs of contraction of the 
anastomotic orifice presented themselves and grew worse, 






DISEASE IN THE SIGMOID FLEXURE. 457 

and she had, in October and November, 1891, several attacks 
of mild obstruction, which were relieved by enemata and 
calomel. On December 22, 1891, I tried, by reopening the 
abdomen, to relieve the condition, but the adhesions were 
so extensive and so firm that I could do nothing, and she 
died from this attempt on the fourth day of peritonitis. The 
autopsy showed no trace of cancerous disease in any or- 
gan. The anastomotic opening, made two years before, two 
and a half inches long, was contracted so as to admit the 
index finger, and the small intestine or several loops thereof 
were entangled in a maze of dense adhesions. The carcinoma 
was excised in January, 1887. She was in good health up to 
October, 1891, and there was no sign of recurrence at the au- 
topsy in December, 1891, being nearly five years. 

" Very truly yours, W. T. Bull." 

I shall make this concise statement by Dr. Bull of this case 
suffice for anything that I have to say in regard to the neces- 
sity and method of operating on such a case. The doctor is 
to be congratulated upon so good a result in so difficult a 
case, and I must say that it was obtained by the brilliant 
manner in which the operation was done. 

Syphilis in the Sigmoid Flexure. — That the sigmoid flexure is 
a seat for syphilitic deposit can be maintained. In dealing 
with the subject of stricture of the rectum, I state that, 
in my opinion, more than one half of the strictures found 
there are due to syphilis ; therefore it is easy to understand 
how the sigmoid flexure, or a portion of it at least, could be 
included in the disease. The early symptoms of syphilitic 
deposit in any portion of the gut are very obscure. Indeed, 
our attention is not often drawn to it until the ulcerative 
process has set up, or a strictured condition results. In 
cancer of the colon, I have said among the early symptoms 
we find diarrhoea. I believe that in syphilitic deposit the 
opposite condition obtains — viz., constipation. Admitting, 
then, without argument, that syphilis can affect the sig- 
moid flexure, we can very well understand how serious would 



458 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

be the trouble in such a case. After an observation of fif- 
teen years, covering many cases, I am constrained to believe 
that syphilitic ulceration of the rectum which has resulted 
in a strictured condition is not curable. The idea that by 
the administration of iodide of potassium and other anti- 
syphilitic remedies reabsorption of this deposit takes place 
is, I am sure, a mistake. The earlier symptoms of a syphi- 
litic deposit along the route of the colon, whether attended 
with ulceration or not, presents very much the same symp- 
toms as a simple inflammation or ulceration. It is the com- 
mon observation that ulceration of a specific character in the 
rectum goes on rapidly to a constriction. Therefore we can 
understand how rapidly this stenosis would occur when the 
ulceration is located higher up. I have observed many cases 
of syphilis of the rectum where the constrictions took in the 
whole length of the rectum proper, and included a portion of 
the sigmoid. 

Treatment. — If the sigmoid flexure is included in this 
syphilitic deposit which may begin in the rectum, it would 
hardly be detected until an ulceration and a subsequent 
stricture existed ; therefore, outside of the local application 
of a soothing medicament and a cleansing of the parts as far 
as practicable, but very little can be done. I have tried the 
constitutional plan of treatment many times, and have got 
very poor results. Therefore I will simply consider the ne- 
cessity of an operation when the upper portion of the rectum 
or the lower portion of the sigmoid flexure is being closed by 
a constriction or a total occlusion takes place. In cancer lo- 
cated in the sigmoid flexure I have been chary about advis- 
ing an operation at all, but in a close constriction or occlusion 
by syphilitic deposit I am very positive that an operation is 
not only warrantable, but should be done ; and that opera- 
tion is colotomy. Under almost every other condition I have 
objected to the operation, but in this character of disease I 
am sure that not only theoretically is it the proper thing to 
do, but practically it has been of wonderful benefit. If a 
surgeon would compare his results as obtained by colotomy 






DISEASE IN THE SIGMOID FLEXURE. 459 

in cancerous stricture and syphilitic stricture of the rectum, 
he will congratulate himself upon the good results he ob- 
tains where syphilis has been the cause of the stricture, and 
deplore his results where cancer has been the cause. If this 
be true when the strictured condition is in the lower part of 
the rectum, it is doubly true when the constriction is higher 
up in the rectum, or when it includes the sigmoid flexure. 
Where a colotomy is done for cancer, it does not in any sense 
tend to cure the disease, and in my cases it has not mitigated 
it to the extent that some claim ; but if the operation is done 
for a syphilitic occlusion of the gut, the patient may live a 
long time, perhaps his allotted days, after colotomy is done, 
the operation having relieved him of the dangers of an ob- 
struction ; and the disease itself may advance no farther. I 
have reported one case where a syphilitic stricture at the en- 
trance of the sigmoid flexure was broken down by introduc- 
ing my hand and arm into the rectum and practicing forcible 
dilatation with the fingers. In the selection of the proper 
method of doing the colotomy in cases of syphilitic stricture 
I would be inclined to advocate the inguinal operation here 
in preference to the lumbar, more especially for the reason 
that there is no disease like cancer to extend to and embrace 
the opening. 

Foreign Bodies in the Sigmoid Flexure.— Because of the pecul- 
iar anatomical construction of the sigmoid flexure it may be- 
come the receptacle of foreign bodies, and by the inflamma- 
tory act or otherwise they may be held there. In such an 
event there can be but one operation done with a view to their 
extraction — viz., cutting down upon the sigmoid and taking 
the foreign body out through the opening and closing the 
incision at once. As we have before stated, the sigmoid may 
be the seat of impacted dry faBces. This condition can be 
usually overcome by irrigating constantly the sigmoid flex- 
ure by means of the Wales rectal bougie and the Davidson 
syringe. If, however, the impaction has as a nidus some for- 
eign substance, such as a small stone or hair, which has been 
swallowed, or possibly teeth, etc., it might become necessary 



460 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

to do a similar operation as suggested for foreign bodies, 
though I have never seen such a case reported. 

Volvulus of the Sigmoid Flexure.— I shall only consider the 
operative treatment of volvulus of the flexure, and for the 
elucidation of the subject I can do no better than to embrace 
the views of Prof. H. Braun, of Konigsberg, as taken from 
a late article in the Archiv fur klinische Chirurgie. The au- 
thor reports three cases of volvulus of the sigmoid flexure 
treated by surgical measures, two of which recovered, and 
presents the statistics of thirty-one cases operated upon by 
various surgeons during the past thirty years. He states that 
the diagnosis of this condition is possible in a comparatively 
frequent number of cases, and regards the following points 
as deserving of especial consideration : 

" 1. The history given by the majority of these patients is 
that they have suffered for a long time from sluggishness of 
the bowels, and sometimes from more or less persistent con- 
stipation, frequently difficult to relieve, and attended with 
distention and tenderness of the abdomen. In many of these 
cases the last severe attack occurs without any apparent cause, 
sometimes after severe bodily exertion, sometimes after inges- 
tion of indigestible substances. 

" 2. The age of the patients is of diagnostic significance, 
most of them being advanced in years. Among fifty cases of 
volvulus of the sigmoid flexure collated by the author there 
w T ere only two persons below the age of twenty years. 

u 3. The sex of the patients is to be taken into consider- 
ation. According to the above statistics of fifty cases, forty 
occurred in males and only ten in females. These figures 
agree with those furnished by Lichtenstern and Treves, but 
are opposed to those of Rokitansky, which, however, are 
based upon a much smaller number of observations. 

"4. The thorough examination of the abdomen is of 
utmost importance. Frequently the markedly distended sig- 
moid flexure can be wholly or in part mapped out by palpa- 
tion. Yon Wahl has especially called attention to the value 
of this symptom. 



DISEASE IN THE SIGMOID FLEXURE. 461 

" 5. Vomiting is a symptom which deserves attention in 
these cases. It is present in most cases of intestinal occlu- 
sion, and frequently becomes stercoraceous. In severe and 
even fatal volvulus of the flexure it may be entirely wanting ; 
usually, however, it is present, but very rarely assumes a 
feculent character. Sometimes it occurs at the beginning 
or toward the end of the other symptoms of obstruction. 

" 6. Another point which maybe utilized for diagnostic 
purposes, but to which attention has not heretofore been 
drawn, is the demonstration of an accumulation of fluid in 
the abdominal cavity. This necessarily takes place whenever 
portions of the intestine with their attached mesentery are 
strangulated, as the result of stasis of the blood in the vessels 
of the affected parts ; its origin is therefore entirely analogous 
to that of the fluid in a hernial sac in cases of strangulated 
hernia. This effusion of fluid may be so considerable in 
amount that it can be detected by palpation, as the author's 
experience has shown. Of course, the symptom is not pa- 
thognomonic of volvulus of the sigmoid flexure ; but is con- 
firmatory of strangulation of a large section of intestine when 
taken in connection with other symptoms, and after the pres- 
ence of ascites or peritonitis has been excluded, which can 
usually be done without difficulty. Aside from volvulus, the 
author has observed this condition in a case of laparotomy 
for strangulation of several intestinal coils by a Meckel's 
diverticulum. 

' ' As regards the methods of treatment in cases of volvulus 
of the sigmoid flexure, we should first attempt to overcome 
the torsion of the gut by injections of water or insufflation of 
air. That these measures have a favorable effect may be as- 
sumed a priori, but is rendered more probable by the special 
experiments of Heiberg, which showed that the intestines in 
dead bodies could be rotated on their axis by insufflation of 
air. Aside from these measures, the taxis has been recom- 
mended by some authors, although little can be found in the 
literature as regards its method of application aud results. 
Kendu advised that after introduction of a rectal tube the 



462 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

patient should be placed on his abdomen and then suddenly 
turned from the right to the left side. Jonathan Hutchinson 
suggested that after the patient had been profoundly anaes- 
thetized the abdomen should be vigorously kneaded, and the 
intestines forced upward, downward, and toward the sides ; 
the patient should then be turned on his abdomen and shaken 
forward and backward, while large enemata were to be given. 

"As a further means of treating volvulus, some authors 
have recommended puncture of the gut as a proceeding unat- 
tended with danger. Heiberg, on the ground of his experi- 
ments on the cadaver, even assumes that an ' untwisting ' of 
the intestine may result directly from the punctures. In 
Braun's opinion, this measure is admissible if the distended 
intestinal loops can be distinctly felt through the abdominal 
wall. Too much should not, however, be expected from this 
auxiliary, since he has found that only a small portion of the 
gut can be emptied in this manner, and hence only a slight 
reduction in volume of the abdomen can be produced. Mul- 
tiple punctures would give a better result, ;but the danger 
of infection of the abdominal cavity is thereby increased. 
Although in the majority of the cases the abdomen may be 
repeatedly punctured in the same individual without injury, 
the development of septic peritonitis from defective closure 
of the puncture can not be excluded with certainty. In a 
number of the cases tabulated by Braun the punctured intes- 
tine had to be sutured, because the openings had failed to 
close spontaneously. This is most likely to occur if the intes- 
tinal walls have lost their contractility. 

" If these measures fail to effect a cure within a short time, 
as is frequently the case, we have to choose between laparot- 
omy, with direct removal of the obstruction, and enterotomy. 
If the diagnosis is quite positive, and the patient is in a hos- 
pital where sufficient assistance can be secured, it will be best 
to perform laparotomy, as was done with success in two of 
the author's cases. If the diagnosis is doubtful, and the ex- 
ternal conditions unfavorable, an artificial anus should be 
established in cases where the abdomen is greatly distended. 



DISEASE IN THE SIGMOID FLEXURE. 433 

If, during the performance of this operation, we find evidences 
of firm strangulation of the gut, laparotomy should be resort- 
ed to at once, or soon after, for removal of the obstruction. 
These evidences are a bluish discoloration or gangrenous ap- 
pearance of the portion of intestine protruding into the 
abdominal wound, or the demonstration of a constricted and 
distended intestinal loop, or the outflow of a large quantity 
of bloody, serous fluid. 

"The question whether in volvulus of the sigmoid flexure 
a cure can be obtained by enterotomy alone can not be settled 
by statistics, since in cases running a favorable course after 
this operation the diagnosis that a torsion has existed can 
never be made with certainty. In establishing an artificial 
anus it is also possible that the distended sigmoid may be 
sutured to the abdominal wall, as has happened in several 
instances, and then the twisted loop would be fixed in a still 
more abnormal position. This faulty fixation is the more 
likely to occur since the sigmoid flexure is quite frequently 
greatly distended, while the intestine above the volvulus is 
empty. 

" In performing a laparotomy, the incision in the linea alba 
is most useful, as by lateral incision any existing volvulus is 
more likely to be overlooked. To release the strangulation, 
the tympanitic flexure should at once be drawn outside the 
abdomen, since, in consequence of its marked distention, it 
can not be rotated into its normal position within the abdomi- 
nal cavity. The withdrawal of the loop may be rendered diffi- 
cult by the shortness of the mesentery of the descending 
colon or the presence of firm adhesions, but, aside from the 
above reasons, it is desirable, as enabling us to observe any 
structural changes of the gut that may be present. Gangrene 
occurs chiefly at the place where both segments of the flexure 
have been twisted on each other. Besides this, there may be 
found linear tears of the serosa, which should be sutured if 
met with during the operation, and may even necessitate re- 
section. 

u If, after release of the torsion, the intestinal walls are 



464 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

found to be in a healthy state, the sigmoid flexure may be 
immediately returned to the abdominal cavity, a proceeding 
which is sometimes attended with great difficulties. It is 
frequently necessary first to puncture the distended and elon- 
gated flexure with a fine needle in order to evacuate the gas, 
and sometimes to suture these openings for the purpose of 
preventing escape of liquid faecal matter. In some cases incis- 
ions may even be required, which are best made in the longi- 
tudinal axis of the gut on the side opposite to the mesenteric 
attachment, and closed with a double suture. If the higher- 
lying intestinal sections are markedly distended, they some- 
times also require to be incised, although this is not likely to 
be of much value if peristalsis is much impaired. Senn, who 
regards incisions of the gut as necessary in all cases in order 
to effect reposition, advises that the patient be placed on the 
side, and then by raising up the intestinal coils the contents 
will gravitate toward the openings whence they are allowed 
to escape. The simplest procedure for this purpose, and one 
which is sufficient for the majority of cases, is to introduce 
a tube into the rectum at the beginning of the operation, 
through which the gases and fluid faeces are frequently evac- 
uated immediately after the removal of the volvulus. If these 
evacuations do not occur spontaneously, it may be advan- 
tageous to irrigate the gut from below. 

" After reposition has been effected it is desirable to adopt 
precautions to prevent a recurrence of the volvulus. Cases 
of this kind have been reported by Roser, Obalinski, and 
Nussbaum. Roser suggested that the mesentery be attached 
to the peritonaeum of the left abdominal wall by sutures, so 
that the upper segment of the flexure, which is apt to be the 
most mobile, is fixed to a sufficient extent. This suggestion 
has not been followed by others. In one of his cases Braun, 
after untwisting the gut, sutured the colon portion of the 
flexure over an area of six centimetres to the left side of the 
abdomen by eight silk sutures ; the result was favorable, and 
this manner of fixation seemed to be more secure than attach- 
ment of the mesentery to the abdominal wall. Recently Senn 



DISEASE IN THE SIGMOID FLEXURE. 465 

has recommended for the same purpose that the mesocolon 
be shortened by establishing a fold parallel to the axis of the 
gut, but Braun thinks this is only practicable in exceptional 
cases. In his opinion, the predisposing factor to the develop- 
ment of volvulus is not, as Senn assumes, a long mesocolon, 
but in the vast majority of cases a small mesentery which has 
undergone further shortening as the result of peritoneal in- 
flammation. In such cases if we follow the suggestion of 
Senn and shorten the mesocolon, a flexion of the gut must 
result. 

' k The steps of the operation are somewhat different if the 
site of volvulus or any other point of the flexure is found in 
a gangrenous condition. If the gangrene is not perfectly 
localized, and suture of the part is not entirely free from 
risk, it is best to resect the entire flexure — the more so since 
the changes in the mucous membrane are often more marked 
than would appear from inspection of the outer surface of 
the gut. Extensive defects of the mucous membrane and 
dirty, grayish, fibrinous exudations are not infrequently met 
with in cases of volvulus of the flexure, where the exterior of 
the gut seems bat little changed. Such lesions would cer- 
tainly have healed with difficulty, if at all susceptible of a 
cure. Whether after resection it is preferable to directly 
unite the ends of the gut, to establish an artificial anus, or to 
perform entero- anastomosis according to Senn's method, will 
depend upon the character of the intestines and the strength 
of the patient. The formation of an artificial anus is accom- 
plished in the most rapid manner, and makes the slightest 
demands upon the patient's vitality, and should therefore be 
preferred in the majority of cases. If the volvulus can not 
be removed, and the intestine is still in a good condition, 
entero-anastomosis rather will be indicated. The suggestion 
of Treves, to puncture the intestine and then perform colot- 
omy at the descending colon should not be adopted. 

U A study of the statistics by the author shows that of 
seventeen cases in which the volvulus was removed by opera- 
tion, six were cured (35*5 per cent) and eleven died. In 

30 



±66 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

two cases, where laparotomy had been performed and the 
torsion removed, a recurrence of the volvulus took place — in 
one immediately after the operation and in the other four 
months later. Both patients died, one of them being sub- 
jected to the second operation. Four cases, in which the vol- 
vulus was not discovered during operation, terminated fatally. 
Of two patients on whom resection of the sigmoid flexure 
was performed, one died on the thirty-second day from per- 
foration of a gastric ulcer, and the other was cured with 
formation of an artificial anus. Eight cases in which enter- 
otomy was done died shortly after the operation. The au- 
thor warns us not to conclude from this statement that the 
establishment of an artificial anus in volvulus of the flexure 
is entirely without value. He is convinced, however, from a 
study of the results, that many of these patients could have 
been saved by an early resort to laparotomy or resection of 
the flexure." 



CHAPTEE XX. 

PROLAPSUS ANI. 

I use the term prolapsus ani in preference to procidentia 
recti for two reasons : First, it is commonly understood by 
the physician, when speaking of these cases, that we refer to 
the prolapse of the mucous membrane of the bowel. Second, 
because this is the form with which we most frequently meet. 
I must say that procidentia of the rectum is a very rare dis- 
ease. In my. own practice I have seen bat three cases. But 
so far as prolapsus ani is concerned, it is much more com- 
mon, especially when we include children in the list. The 
fact that in children there is no distinct curve to the sacrum, 
and no stout resisting sphincter muscle at the outlet, together 
with the fact that they generally strain violently at stool, ac- 
counts for this condition. Most any physician that has had 
much practice can recall perhaps a number of cases of pro- 
lapsus ani in children, and it is not regarded as a very serious 
affection. Mothers, however, are greatly alarmed when sud- 
denly discovering the rectal prolapse in their child. A mes- 
senger is generally sent for the physician, but by the time 
he has arrived the protruding mass has returned of its own 
accord. I shall never forget a case of this kind that oc- 
curred in my early practice. I was sent for to come hur- 
riedly, a distance of several miles, to see a child to which had 
happened some terrible accident. Upon my arrival, I found 
the mother in great distress. She said to me between her 
sobs that the body of her child had come down and that she 
feared that it was in a dangerous condition. The little fellow 
was lying on the bed, and I could see the prolapse before I 
got to him. My first impulse — which I carried into execution 



468 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

— -was to pick him up by the heels and shake him that the 
prolapse might go back by gravitation. No sooner had I 
done this than the mother, approaching from behind, dealt 
me a terrific blow on the back of the neck and knocked me 
down. I fell, with the child under me, but when I regained 
myself and lifted him up the prolapse had disappeared. Of 
course she begged my pardon, but it did not relieve the sting. 

I recognize the fact that, anatomically, the term prolapsus 
ani is an incorrect one, and yet usage permits its adoption. 
However, in dealing with the subject, I shall only refer to the 
prolapse of mucous membrane out of the rectum, and shall 
not include internal haemorrhoids, which are frequently pro- 
lapsed, and very often mistaken for a true prolapse of the 
bowel. It would seem strange, considering the literature 
upon the subject, that this mistake could be made ; but it is 
of very common occurrence for me to see such cases that have 
been so diagnosticated. 

Case. — Two years ago I received a letter from a physician 
in a distant State, saying that he had a patient that he de- 
sired to refer to me for an operation, or at least for my advice 
whether an operation was advisable or not. He mentioned 
the fact that he had never examined the patient himself 
for the reason that he did not do such surgery, but was in- 
formed by the patient that a year previous to that time, while 
living in a distant city, he had consulted a surgeon, who 
made an examination and advised him to be operated on for 
a large prolapse of the bowel. The operation was undertaken, 
but he was allowed to come from under the influence of the 
anaesthetic, when he was told that it was impossible to remove 
the prolapse. But since that time it had become very dis- 
tressing and caused him a great deal of pain and uneasiness, 
and he desired a second attempt to be made, hence was re- 
ferred to me. Upon his arrival he detailed to me very much 
the same as what the doctor had written. I did not deem it 
necessary to make an examination until he was placed under 
chloroform. He was prepared for several days, and upon the 
day set for the operation I found him nervous and agitated, 



Plate VI 




PROLAPSUS ANI. (MATHEWS. 



PROLAPSUS ANI. 



469 



laboring under the belief that he would die under the opera- 
tion. I succeeded in quieting him of his fears, and he was 
given the anaesthetic. When I divulsed the sphincter muscle 
in order to bring down the prolapse, what was my surprise to 
find a large mass of hemorrhoidal tumors presenting ! It was 
very true that they were in size much larger than is ordi- 
narily found, but there was no prolapse of the bowel proper at 
all. I transfixed and tied each tumor, then cut off each one 
of them and returned the stumps into the bowel. He did not 
have an untoward symptom, and went home at the end of 
two weeks. I simply cite this case to show not only that 
these mistakes are often made, but also to advise that the 
operator be very careful in taking the opinion of the patient, 
or listening to his stories in so far as the diagnosis is con- 
cerned. 

Allingham deals with procidentia as being a descent of 
the whole circumference of the rectum. For the sake of 
division this is a very good idea, and yet we can have a severe 
form of procidentia without having the whole circumference 
of the rectum included. He says this may take place in three 
ways : First, when the entire circumference of the mucous 
membrane, or all the coats of the rectum, are clear outside of 
the anus. Second, when the upper part of the rectum de- 
scends through the lower part, and then appears outside the 
anus. Third, when the upper part of the rectum descends 
through the lower part, but does not appear outside the anus. 
I am much inclined to believe that the term prolapse and 
procidentia would be sufficient to explain the condition that 
happens. The two latter varieties described by Allingham 
are really cases of intussusception, and do not fall in the class 
that we are describing. For the sake not only of brevity but 
also of treatment, I think it best to rule out these two during 
this consideration. Indeed, I think the term procidentia, as 
applied to the rectal prolapse, is a faulty one at best. It was 
borrowed from uterine nomenclature and should be returned 
to it. To my mind, the terms simple prolapse as referring to 
the protrusion of the mucous membrane alone, and compli- 



470 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

cated prolapse where it was accompanied with invagination, 
etc., would better express the real condition. Some authors 
designate them as " partial" and " complete," and yet so very 
few cases of procidentia are complete that it amounts to an 
anatomical curiosity. Indeed, Boyer, who up to the publica- 
tion of Nelaton's Surgery was the greatest French authority, 
denied that it was possible for the whole rectum to be dis- 
placed from its connections and forced out through the anus 
in the form of what we call "complete prolapse." Had he 
been content with this simple statement, many would have 
been prepared to accept it ; but he went further than this 
and. said that all anal protrusions consisted of mucous mem- 
brane alone, and that the external connections and attach- 
ments of the rectum rendered its extrusion in totality an im- 
possibility. Cruveilhier was the first authority, to my knowl- 
edge at least, who, by dissection of the part of the dead body, 
proved that complete prolapse of the rectum could take place, 
and yet the condition is so rare that a surgeon scarcely in a 
lifetime would meet with it. In dealing with the two forms 
of prolapse, I would say that the simple variety was that of 
mucous membrane alone, and the complicated included more 
or less of the peritoneal .sac. Really this is the most im- 
portant thing to be known in making a diagnosis, especially 
when treatment is under consideration. Esmarch says that 
when prolapse is extensive a pouch of peritonaeum is formed 
by the anterior wall, in which a coil of small intestine or the 
bladder or even the ovary may be lodged. This would indi 
cate to us the danger in dealing with the procidentia at all ; 
but the one particular thing which we wish to know is, 
whether a pouch of peritonaeum itself is included in the 
prolapse. Therefore, as the diagnosis is the most important 
point of this trouble, I can do no better than to quote from 
Van Buren when he says : 

"Of complete prolapse, in which the whole thickness of 
the bowel is included, there are three distinct varieties, each 
of which the well-informed surgeon should be able to dis- 
tinguish: 



PROLAPSUS ANI. 471 

"1. The most common form, in which the greased finger, 
passed carefully around the base of the tumor, recognizes 
that its external surface is absolutely continuous with the 
membrane that lines the orifice of the anus without the exist- 
ence of a sulcus. Here the bowel began to slip out originally 
by its very lowermost portion, and this had gradually formed 
the outer layer of the protrusion, the gut, as it is forced 
down from above, passing within it. This form of complete 
prolapse follows simple protrusion of the mucous membrane, 
or partial prolapse when the latter has been neglected ; it 
results from a persistence of the causes which are keeping up 
the latter, and effecting its gradual increase by dragging upon 
the outer coats of the gut when the submucous connective 
tissue will no longer yield. Such a tumor always contains 
more or less peritonaeum, and it is important that you should 
never lose sight of this fact. The peritonaeum, you will re- 
member, surrounds the rectum on all sides and extends 
downward to an oblique line three inches and a half from 
the anus in front and scarcely five behind. The peritoneal 
reflection, at the base of a protrusion of this kind, is there- 
fore always larger in front. 

"2. Where the finger can be inserted into a groove along- 
side of the base of a tumor, so as to recognize a distinct sul- 
cus of more or less depth, at the bottom of which, if not too 
deep, the lining membrane of the gut can be felt as it is 
reflected from the base of the protruding tumor. In this case 
the rectum has begun to fold upon itself. In other words, to 
become invaginated, or, in the language of the day, 'tele- 
scoped,' the upper part of the bowel always passing within 
the lower, at a point more or less distant from the anus, yet 
generally within the reach of the finger. 

"3. In this variety the finger can be inserted through the 
anus alongside of the protruding tumor, but can not reach 
any line of reflection of the mucous membrane of the rectum 
upon the tumor ; the latter, in fact, may not even as yet have 
protruded externally through the anus, but may be felt only 
as a polypoid mass, occupying the cavity of the rectum. 



472 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

Here invagination has taken place higher up in the colon ; 
has possibly commenced in the caecum or even in the lower 
part of the ileum, which, sucked through the ileo-csecal valve, 
has been carried with the caecum itself up the ascending 
colon, and, the connecting attachments gradually yielding, 
the invaginated mass has been propelled along the whole 
length of the colon and finally presents itself in the rectum, 
or may be possibly protruded externally. This almost in- 
credible displacement of the parts has now been certainly 
recognized in so many recorded cases, examined after death, 
that it were inexcusable to fail to recognize it during life." 

Now, although these three varieties of complete prolapse 
are simply examples of the same affection, and differ only in 
degree, they are so very different from what we understand 
prolapsus ani to be, that I really believe they should be rele- 
gated to another department of surgery. 

There could be no objection, in the consideration of rec- 
tal surgery, to dealing with prolapse of the rectum alone, 
or prolapse of all the coats of the rectum ; but the other two 
varieties are very different conditions, and should be consid- 
ered as such. 

Diagnosis.— It might appear a simple matter to diagnosti- 
cate a case of simple prolapse of the rectum, and yet, as I 
have intimated, mistakes are very often made. In children 
it is an easy matter to come to a correct conclusion, from the 
fact that we do not anticipate meeting with haemorrhoids, 
etc., with which simple prolapse is frequently confounded. 
Therefore I would suggest that, in the adult, the patient 
be requested to take an enema and to strain down, and 
then the surgeon to inspect the protruded part. If it be 
a prolapse of the mucous membrane, it will occupy the 
most or all of the circumference of the bowel, with a cer- 
tain degree of regularity. The gut will be of a bright-red 
color, and if placed between the fingers its folds can be 
easily pressed together, there being no well-formed tissue 
existing. In protruded haemorrhoids the condition is very 
different. We have an irregular prolapse, which does not 



PROLAPSUS ANI. 473 

include the circumference of the bowel, but oftentimes ex- 
ists only on one side ; and if the parts are taken between 
the fingers a well- organized tumor can be felt, which can be 
circumscribed, and the color is a dark blue. The clinical 
features, in a complete prolapse of the rectum, are of either 
one of the three varieties mentioned by Van Buren, and are 
very different from what I have described. To keep these 
three varieties in mind it is best, as he says, to remember, 
viz., the first and most common, where there is no sulcus at 
its base, but pretty certainly a pouch of peritonaeum within 
its substance ; the second, where there is a sulcus, but the 
finger when inserted can readily touch the bottom of the 
groove ; and third, where the finger can reach no line of re- 
flection, and the history of the case and palpation of the ab- 
domen may complete a diagnosis of intussusception, com- 
mencing high up in the canal. 

I think that one of the most prominent, and at the same 
time most important, features to be taken into consideration 
in differentiating between simple and complicated prolapse of 
the bowel is the size of the mass which protrudes. Simple 
prolapse is never very large, and where any of the coats of 
the rectum or all of its coats are included, the protrusion is 
much larger. A simple prolapse of the bowel does not usu- 
ally remain out for any length of time, and a prolapse con- 
taining the coats of the rectum is very apt to remain out an 
indefinite length of time, or until it is returned. There are 
a few rare instances recorded where the whole bowel has come 
out and quickly returned. 

Procidentia varies very greatly in size, although any form 
of procidentia is larger than a simple protrusion of the mu- 
cous membrane, and it may be as large as the foetal head. 
The case which I record, and which will be observed as one of 
the colored drawings, was as large as the ordinary foetal head 
and much longer. 

I have said that the statement of the patient may fre- 
quently mislead us in making up our. opinion as to what 
really protrudes, and that in a majority of cases it will be a 



474 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

prolapse of hemorrhoids instead of a true prolapse of the 
bowel. There is one special point that I wish to speak of 
here, in making an examination, which can be best detailed 
by giving a case. 

Case. — A young lady was brought to my office a short 
time ago, when a clear history of a protrusion from the 
bowel was given. I supposed, of course, it was hemor- 
rhoidal. She mentioned the fact that it would remain out for 
quite a while unless she reduced it. I directed that, after the 
evacuation of her bowels the next morning, she should allow 
the protrusion to remain out, and that I would call by at a 
certain hour and examine her. I went at the time named, 
and she said it had remained out about twenty minutes but 
had gone back again. I inserted my speculum, and when I 
distended it and brought into view the surface of the rectum, 
no hemorrhoidal tumors could be seen at all, but, to the con- 
trary, the mucous membrane was perfectly smooth, and yet 
to this ocular inspection no condition could be seen which 
would indicate a prolapse. Now, the point which I wish to 
impress is, that it is impossible to make out with the specu- 
lum any special condition which would lead us to believe that 
the bowel would prolapse, or aid us in the least in making up 
a diagnosis. This is the second case in my experience where 
I have been deceived as to the nature of what it was that 
really prolapsed at stool in my patient — that is, I mean to 
say, the second case where a prolapse really did occur which 
was not hsemorrhoidal. Therefore I would impress the fact 
that the best way to substantiate the belief that a prolapse of 
the bowel exists is to see the bowel when it is prolapsed. 

Causes. — In children a prolapse of the bowel is usually the 
result of straining at stool, which may be induced by the ex- 
istence of worms, loose bowels, etc. Very slight causes will 
produce the condition in children when the same causes 
would not produce it in the adult. I believe that in women, 
especially those who have borne many children, prolapse of 
the bowel is more likely to occur. In men, the pelvic muscles 
aid very materially in keeping up the rectum. I have parents 



PROLAPSUS ANI. 475 

very often say to me that they are not surprised that their 
child has prolapse, although perhaps grown, as in its early 
infancy it suffered from the same thing. This is a mistake, 
as it is to haemorrhoids they are referring in the child grown, 
and to a prolapse in the child as an infant. In the adult a 
prolapse may be brought about by excessive straining, caused 
by dysentery, diarrhoea, worms, an enlarged prostate in the 
male, stone in the bladder, a polypus, etc., and yet without 
any of these causes we may witness a case of the kind. It is 
said to be often the result of strumous inflammation of the 
intestines. I am sure that the notable case which I here 
record was due to a syphilitic inflammation of the bowel. 

Case. — The following notes have been prepared by Dr. 
E. P. Miller, the very efficient Interne of the Louisville City 
Hospital, who has assisted me materially in the case. " Kate 
W., white, aged twenty-six, admitted to City Hospital, No- 
vember 14, 1891. Condition at time of admittance : A large 
growth about the size of a child' s head, protruding from rec- 
tum, which was in fact a prolapsus recti, with great infiltra- 
tion and an apparent overgrowth of all the tissues involved. 
The mass filled the whole of the vaginal cavity and protruded 
through the vulva. The peritonaeum was torn through, ex- 
cept a small transverse band anteriorly, by the growth, which 
was constantly increasing in size. There was some irritation 
of the bladder ; abdomen distended ; evacuations of a watery 
mucous character. The patient suffered great pain constantly 
in her abdomen and legs, and was unable to walk. She could 
not lie on her back on account of the pain induced by the 
pressure of this enormous growth. 

"Previous History. — Father dead ; cause, senility. Moth- 
er dead ; cause unknown. Three of the family living ; one 
has phthisis, the other two healthy. Three of the children 
dead. One died of tetanus. Cause of death in the other two 
unknown. Patient was in good health during infancy and 
childhood. At the age of fourteen she was seduced, and in 
a short time a venereal sore appeared. She was brought to 
the City Hospital for treatment, and remained here for six 



476 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

months. At some time during her stay at the hospital she 
was operated on for a large condylomatous growth on the 
right vulva. After leaving the hospital she went to her 
friends and lived for three or four years, after which she en- 
tered upon a sporting life. This life was kept up for about 
three years, and during the time she contracted a disease 
which appeared in the form of an eruption all over her body. 
We must suppose that it was syphilis, as there was a general 
glandular infection and alopecia following. At the age of 
twenty she was married. One abortion and one living child 
followed the union. Child died at the age of two years ; 
cause said to be measles. Patient had always been more or 
less affected with constipation. Some time after marriage an 
ulceration appeared on both legs, was treated, and healed for 
a short time, and then reappeared and was again treated with 
the same result. The patient's rectal trouble began sixteen 
months before being admitted to the hospital. The proci- 
dentia, which was then very manifest, gradually increased in 
size and gave her great pain. She soon began the use of 
opium to relieve this pain, and when admitted to the wards 
it required as much as a grain and a half at each dose to re- 
lieve her. From November 14, 1891 (date of admittance), to 
December 3d of the same year nothing was done for her 
except to administer opium for the relief of pain, it being 
thought best to watch the case, especially for an intestinal 
obstruction, expecting that a colotomy would be required for 
the same. For numerous reasons, the operation was not 
thought advisable, and she was ordered on December 3d to go 
under constitutional treatment ; consequently on that date 
the anti syphilitic medication was begun — viz., the giving 
of mercury and iodide of potassium. This treatment was 
pushed to its full effect. In addition to this, the rectal mass 
was washed twice daily in a solution of l-to-500 bichloride 
of mercury. In ten days from the time the treatment was 
begun the visible portion of this large mass began to disap- 
pear, and at this present writing — January 24, 1892 — she is 
taking daily one hundred and fifty grains of the iodide of 



PROLAPSUS ANI. 477 

potassium, and the mass has reduced to one third of its origi- 
nal size. 

"Dr. Mathews saw her to-day and expressed the same 
opinion as is here stated— that the mass had reduced at least 
one half since the beginning of the treatment. The patient 
still suffers a great deal of pain, and it requires as much as 
sixteen or twenty grains of morphine hypodermically every 
day to relieve her." 

There are several important points in this case to which I 
wish to call attention : First, that it was a complete prolapse 
of the rectum, but not in the ordinary acceptation of the 
term. Not only was a prolapse observed, but by an examina- 
tion it was revealed that we had a veritable growth to deal 
with. In making the examination per vaginam, the front of 
the mass could be felt as a great solid tumor, and, as Dr. Mil- 
ler suggests, protruded through the vulva. On the pro- 
lapsed bowel were two or three distinct elevations, due to 
syphilitic infiltration. From the time of the original pro- 
lapse to the time that the case is reported it was impossible 
to reduce it. It was not only as large as a child's head, but 
it was as firm as a fibrous tumor. This woman was plainly 
a syphilitic, and this deposit or infiltration was, without 
doubt, due to the disease. When the surgical staff met in 
consultation, every point was carefully weighed in the 
case and, as a reduction of the growth was impossible, we 
considered only two propositions : First, to remove the 
growth in its entirety. Second, to open the colon. Consid- 
ering the low vitality of the patient and the danger attend- 
ant upon doing the operation looking to the removal of the 
growth, it was thought that a colotomy would possess some 
advantages ; chief among these, that the irritation caused by 
the passage of faBces would be prevented, and that then, per- 
haps, the woman could be brought up to a better physical 
condition and a radical operation performed after this. Of 
course it was recognized that a colotomy was nothing more 
than palliative in the case. Certain things presenting pre- 
vented the carrying out of this opinion, and it was decided to 



478 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

place the patient under a strict antisyphilitic medication, 
hoping for a reabsorption of a portion at least of the infil- 
trated mass. How well the treatment met the indication can 
be judged by Dr. Miller's report : 

Second. I have already put myself on record in saying 
that I do not believe that a strictured surface within the rec- 
tum from syphilis can be absorbed, and here is an actual 
demonstration that a syphilitic deposit has been reabsorbed. 
I wish to draw the point that one is inflammatory in its na- 
ture, or rather is an infiltration from syphilis, without the 
changes which go to make up a stricture ; that after a strict- 
ure is formed we have a structure which is fibrous in nature 
and resists all efforts at reabsorption. We are fully aware 
that the syphilitic deposit in the throat or in many tissues of 
the body is taken up through the aid of antisyphilitic medi 
cation. So, of course, the same thing occurs in this deposit 
of the rectum, and the case that I report is a beautiful illus- 
tration of the same. 

There is one unfortunate circumstance connected with this 
case which is likely to follow all cases of a similar kind. I 
allude to the fact that the patient has become an opium-eater. 
As she was already this before she entered the hospital, of 
course we are not responsible for it, but it is a melancholy 
condition at best, more especially in this case, as the woman 
can not take care of herself because of poverty, even if she 
was relieved of her disease. 

Treatment. — Considering the division that we have made 
of simple and complicated prolapse of the bowel, we must 
of necessity divide the treatment into two heads : 1. Pallia- 
tion. 2. Operation. 

We have mentioned the fact that simple prolapse of the 
bowel is a common affection with children, and have tried 
to explain the reason. In the first place, therefore, the 
mother or nurse should be instructed that the child should 
never be allowed to go to stool by itself, but that an attend- 
ant should see to one point especially : that after the bow- 
els have been evacuated no straining should be allowed in the 



PROLAPSUS ANI. 479 

child, which object can be attained by immediately taking it 
off of the commode. It has been suggested that in children 
who suffer with prolapse, they should never be allowed to 
sit down at stool, but should assume the erect or recumbent 
position during the act, while the nurse carefully guards 
against the protrusion. If the bowel should come out, it 
should be bathed in cool or cold water and carefully re- 
turned. If the child is constipated, some pleasant laxative 
should be kept on hand and administered, in order to keep 
the actions soluble. I have found it to be quite a good idea 
to move the bowel in these cases by an enema of pure water, 
carefully watching that no straining effort occurred during 
defecation. But the physician will be often summoned to 
a child who has had its bowels prolapsed and the mother 
has been unable to return the mass. It will be found that 
the mother or nurse usually places the child across the knees, 
and by the pressure of the hand or fingers is enabled to push 
the protrusion back into the bowel. But this effort may 
sometimes fail, and because of the time that the protrusion 
has remained out it has become livid and cedematous, and 
the physician will be sent for to reduce it. In many cases 
of the kind it will be found a very difficult job to effect this ; 
but the plan should be about this : The mass should be 
washed first with cold water, then anointed with vaseline, 
and the finger passed through the orifice into the rectum, 
and taxis practiced around the finger, during which effort 
the child should be placed upon its elbows and knees. If 
it resists such position, it can be held in it by force. Or, 
as I have suggested, if the child be completely inverted, the 
mass can be more easily pushed back. It has been advised 
that, under these circumstances, the index finger be covered 
with a silk or linen handkerchief, then inserted into the 
rectum, and by the presence of the material on the finger the 
mass is more likely to go back with it. If these measures 
fail, it is the proper thing to administer ether or chloroform, 
and then in the relaxed condition, which includes that of 
the sphincter muscle, the growth is easily pushed back. It 



480 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

should be ascertained whether there is a primary cause in 
this child for the condition of prolapse, such as worms, phimo- 
sis, etc. ; and if so, these conditions should receive prompt at- 
tention. It will be observed, as a rule, that if the prolapse has 
been reduced often, it is more liable to come down again and 
to remain down ; therefore, in treating the child, some atten- 
tion must be paid to this fact. Having given explicit direc- 
tions concerning the child during the act of defecation, it is 
necessary to begin a treatment looking not only to palliation, 
but a cure, if possible, outside of an operative procedure. 
Therefore, after the bowels have moved and the prolapse has 
been returned, a piece of soft sponge, absorbent cotton, or 
some oakum can be fitted over the anus as a compress, and 
adhesive strips applied transversely across the nates ; this 
to be removed at the approach of the hour that the bowels 
should move as directed. But I have found that the in- 
jection plan with these little patients answers an admirable 
purpose and often effects a cure. Therefore I am in the 
habit of advising the nurse to administer an injection of cool 
or cold water to the patient immediately preceding the act of 
defecation each day ; and just as soon as the act is completed 
to put on the dressings as suggested. It will be often found 
necessary to medicate the water with some astringent. One 
of the best, in my opinion, is fluid hydrastis. In cases like 
this I frequently use it in a pure state, depositing one or two 
drachms in the rectum, and holding it in by means of a pad 
over the anus. As a substitute for this, the muriated tincture 
of iron, tannin, an infusion of krameria, a decoction of white- 
oak bark, etc., may be used. I do not like the plan of insert- 
ing suppositories. I must, however, deprecate the use of the 
application of nitric acid or any strong acid to the rectal mu- 
cous membrane of a child. Indeed, I have seen such a method 
followed by serious trouble in the adult. 

Case. — A young woman, aged twenty-three, came to me 
for treatment for prolapsus. I had her take an injection, and 
by a straining effort cause the protruding of as much of the 
mass as she could possibly get out. The bowel protruded 



PROLAPSUS ANI. 481 

for several inches and appeared to occasion the most intense 
pain. As soon as I inspected the parts I conld easily ac- 
count for this. Located on each side of the mass was a 
very large, angry-looking, suppurating ulcer, and being at 
a loss to understand what had produced the condition, I 
asked her for her previous history. She told me that a 
number of months prior to this examination she had been 
examined and treated for this prolapse by the application of 
pure nitric acid, which was done under the effect of chloro- 
form. Not knowing whether her statement was correct or 
not, I wrote to the physician who had treated her, and he 
told me that it was. It can be easily understood, then, 
that the application of the acid produced the ulceration 
to which I refer, and yet had accomplished no good in the 
way of a cure, but had added materially to her distress. I 
have never yet seen a single case in which I could get my 
consent to apply any strong acid for the purpose of cure for 
prolapsus. First, because if it be a simple prolapsus, there 
are milder and better means that can be used for its cure. 
Second, that if the peritonaeum is included in the folds of the 
prolapse, there would be great danger of exciting to a general 
peritonitis, and even if the patient should escape this, the ap- 
plication of such remedies might produce an intractable ulcer- 
ation or a stricture of the bowel. 

Yan Buren, in discussing the subject of prolapsus ani, 
recommends an operation which has been adopted by a num- 
ber of authorities, and consequently credit is always given 
him for the same. Therefore I deem it best to give the op- 
eration in his own words : " Having etherized the patient, 
elevated the hips as in Sims's position, reduced the prolapse, 
and introduced a speculum, proceed to draw a line upon the 
mucous membrane with the Paquelin thermo-cautery, at a 
dull-red heat, parallel with the axis of the gut, and repeat this 
four or five times at equal distances, carrying the cautery each 
time from a point three inches or more above the anus, slowly 
down through its orifice, and terminating the line of eschar 
externally, where the delicate integument covering the sphinc- 

31 



482 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXUKE. 

ter joins the true skin. You will thus have a series of par- 
allel, vertical stripes of cauterized tissue, the lower extremi- 
ties of which will appear as rays diverging from the anus. 
The lines of eschar may be made more numerous, deeper, and 
broader, according to the volume and duration of prolapse. 
In a child, or where the protrusion is not voluminous or of 
very long duration, I would use a delicate cautery, perhaps 
no thicker than an ordinary probe, but for a larger tumor in 
an adult a more bulky iron ; but in any case it should be 
bent nearly to a right angle a short distance from the button 
at its extremity, so that this may reach all points of the con- 
cavity of the rectal surface. By operating in this manner, I 
believe you would get the full effect of the cautery in produc- 
ing rectal cicatrices with the least amount of danger of subse- 
quent stricture. Where, after cauterization, a cicatrix is left 
which encircles the whole circumference of the bowel, con- 
striction in some degree must follow. In a very bad case an 
operation of this kind might be repeated, new lines of eschar 
being made in the intervals of the old one. This I did in the 
case of a young girl of thirteen, with defective intelligence, 
who had an enormous prolapse which had existed from in- 
fancy. In this case I added to the linear eschars small scat- 
tered points, made with a slender probe-pointed cautery ; the 
effect of the latter, when applied over the sphincter, was re- 
markable in arousing its contractility." 

I have quoted thus extensively from Van Buren that his 
operation might be fully understood. Of course, he based 
his conclusions for a radical cure upon the fact that the in- 
flammatory exudate, poured out as the result of the applica- 
tion of a hot iron, could hold the prolapse in place. I tried 
this plan suggested by Van Buren in a well-defined case that 
fell under my observation, and, although it was practiced in 
full accord with his directions, the cure was anything but a 
radical one. There has been a number of operations proposed 
for the relief of prolapsus ani. Dupuytren thought that to 
diminish the diameter of the anus, and also the bowel just 
within, by removing with strong scissors an elliptical fold of 



PROLAPSUS ANI. 



483 



integument at three equidistant points, the fold including the 
skin just without, and also a portion of the membrane just 
within the orifice, could accomplish the cure. Robert, a 
French surgeon, and Dieffenbach, a German, suggested the 
cutting out of wedge-shaped masses from the over-dilated ori- 
fice, after applying deep sutures, close the wound, and thus 
diminish the outlet ; and Dieffenbach passed stout ligatures 
beneath portions of the prolapse near its base, and, making 
traction, cut out with strong curved scissors a portion thus 
drawn down upon, and even in some cases extirpated the 
whole mass. Valentine Mott modified Dupuytren's operation 
by removing several larger elliptical portions entirely from 
the mucous membrane and drawing together the edges of the 
resulting wounds by sutures. Neither one of these three 
operations has stood the test of time, and consequently can 
not be recommended. 

Dr. Charles K. Briddorj reported to the New York Surgi- 
cal Society, October 8, 1890, a case of prolapse of the rectum, 
operation and recovery, which meets so fully my idea of how 
the operation should be done that I take pleasure in repro- 
ducing his report here : 

"Emma EL, aged thirty-two, married; no morbid family 
history. General health had always been good. Her present 
trouble dated back to an early period of childhood. With 
every defecation there had been a protrusion of the bowel 
through the anus, the condition being much aggravated when 
the bowels were constipated. When riding, traveling, or 
engaged in any other active exercise, the patient had always 
had a feeling of insecurity, due to a partial loss of control 
over the sphincter. She had one miscarriage and one normal 
labor nine years ago. For a period of two years following 
the birth of her child she had suffered little inconvenience 
from the prolapse. Her symptoms had all returned, however, 
and seven years ago she had undergone the operation of 
linear cauterization, which was followed by temporary relief. 
Her symptoms had again returned, and she desired a cure by 
operation. The perinseum having been shaved and scrubbed 



484 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and the parts made aseptic, the prolapsed mass, five inches 
long, was drawn down through the anus and thoroughly ex- 
posed, a procedure easi]y accomplished, owing to the relaxed 
condition of the sphincter. The patient was then placed upon 
the back with her thighs separated and elevated as in the lith- 
otomy posture. An incision was made transversely through 
the mucous membrane on the anterior aspect of the prolapsed 
gut, a little below the verge of the anus. The dissection was 
then continued, the haemorrhage being checked with clamps. 
The peritoneal pouch of Douglas was then opened. The 
danger of infection at this stage of the operation was min- 
imized by frequent irrigation with Thiersch's solution. The 
peritoneal cavity was then closed off by uniting the two op- 
posed serous surfaces by Lembert sutures of fine catgut 
above the line of division. The prolapsed portion of the rec- 
tum was then ligated en masse with an elastic ligature and 
cut away with a few sweeps of the scalpel, and the approximal 
end of the gut slipped up within the anus. It was brought 
down and, after the application of a very large number of 
ligatures, which were required to control the haemorrhage, its 
mucous membrane was sutured with silk to the mucous mar- 
gin of the anus. The sutures last introduced were left long, 
the ends hanging from the anus. The site of operation was 
irrigated, a morphine suppository inserted, and the operation 
completed by the application of an antiseptic dressing and a 
T-bandage. The portion of gut removed measured over Hve 
inches in length. There was some rise of temperature on 
the third day, with nausea, eructations of gas, and tym- 
panites. The patient convalesced steadily and regained per- 
fect control over the rectal sphincters." 

I am satisfied that if a radical operation is called for in a 
case of prolapse of the rectum of the kind mentioned, the 
operation done by Dr. Briddon is the one that should be 
sanctioned. And yet I am sure that had the patient fallen 
into less expert hands, a cure could not have been reported. 
Another thing in favor of a radical operation to-day is that 
we are living under a new regime, and it must be conceded 



PROLAPSUS ANI. 485 

that no such operation as he did could have been done suc- 
cessfully without the antiseptic precautions that he practiced. 
In this connection I desire to say that Dr. Frederick Lange, 
of JN"ew York, has reported a new operation for the cure of 
prolapsus ani, and I therefore embrace what he says. 

"The operation about to be described was devised to 
meet the necessities of the following very aggravated case : 
For almost twenty years Mr. P. Gr. had been suffering from 
prolapsus recti, with more or less incontinence. It seems 
that an inflammatory disease of the rectum (probably dysen- 
tery), accompanied with intense tenesmus, was the original 
cause. He had been operated upon a number of times after 
the usual method (cauterization and excision of the mucous 
membrane), but apparently with only transient and partial 
relief. After one operation, done by my colleague Dr. Adler, 
he was improved for several years. Altogether he had under- 
gone five different operations, when, in October last, he was 
readmitted into the German Hospital. He suffered from in- 
continence as before. The anal ring was quite relaxed and 
wide open, and even with a slight pressure the rectum was 
pressed out. The patient assured me that the prolapse was 
at times worse than ever before, and from Dr. Adler's state- 
ment I concluded that formerly the rectum would protrude 
to the length of fully six inches. I operated in the following 
manner : The patient was fixed on the table in the knee-elbow 
position, a thick cushion placed between his knees and under 
the lower part of his thorax and the upper part of his abdo- 
men, giving a sufficient support. His legs were tied to the 
table and his head rested sideways on a pillow. I have lately 
performed almost all my rectal operations with the patient 
in this position, and I can not recommend it enough. The 
haemorrhage is decidedly diminished, the parts are all more 
accessible, and the principal vessels can nearly all be secured 
before they are divided. An incision was carried from the 
lower part of the sacrum down to the anus, until the posterior 
wall of the rectum was reached. I then removed the coccyx, 
for two reasons : First, I wished to narrow the gut up as far 



486 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

as possible ; and, secondly, I thought that the proposed 
action of the levator ani might thus become less impeded. 
The lumen of the rectum was narrowed in such a way that 
buried etage sutures of iodoform catgut were introduced, 
which did not perforate the entire thickness of the gut, the 
first row being inserted near the middle line, and forming a 
fold in the posterior wall, which protruded against the rec- 
tum. In this way the more lateral portions of the gut, so far 
as it could be done without causing too much tension, were 
brought into apposition ; then the surfaces of the levator 
ani and sphincter externus, which had been dissected back, 
in order to lay bare the posterior walls of the rectum, and 
next their cut surfaces were united by similar sutures. In 
order to secure a more lasting union, several buried sutures 
of silkworm gut were also inserted into the muscular crest. 
Finally, a few sutures in the integument were introduced, 
and the cavity corresponding to the removed coccyx was left 
open and loosely filled with iodoform gauze." 




Satchel for rectal instruments. 

It will be noticed, of course, that this operation was done 
also under antiseptic precautions, and we must believe that 
in recommending operations looking to the radical cure of 
prolapse of the rectum, they must be done in an antiseptic 
way, or the danger is doubly increased. I wish also to draw 



PROLAPSUS ANI. 487 

attention to the fact that in both the operations which I have 
quoted, cauterization by the Paquelin instrument had been 
practiced previously. 

The methods of treating prolapsus ani in a radical way 
have not been very successful in the past, and I am there- 
fore pleased to record two such successful cases in the hands 
of such distinguished surgeons as Drs. Lange and Briddon. 
Theoretically, I have often been impressed with the idea that 
the linear cauterization as suggested by Van Buren was a 
good plan, but after giving it a thorough trial I abandoned it, 
for the reason that it did not meet the promises which had 
been held out. This verdict is corroborated by a recital of 
the two cases just mentioned. Of course, the operation prac- 
ticed by Dr. Lange could not have been done on Dr. Brid- 
don's case, but I am inclined to believe that it will meet the 
occasion in quite a number of instances. But for the radical 
cure of procidentia I am sure that I like Dr. Briddon's plan 
best. But we must face the fact that cases which require the 
radical cutting operation at all are very rare. A prolapse of 
the rectum, which requires some surgical treatment for its 
radical relief and which includes the mucous membrane only, 
is of very common occurrence ; and it is more necessary, in a 
treatise of this kind, to speak of these than of those which 
require a serious, dangerous, and radical operation. 

Therefore, conceding that simple prolapse of the bowel is 
more frequently met than complete prolapse, and that often- 
times it requires surgical treatment, it is a matter of some 
concern to know which is the best way to deal with such 
cases. In a great many of them, especially in children, where 
the rules that I have laid down are observed, and the local 
applications, in the form of astringents, are made and the 
general health looked after, and any cause which may have 
produced the prolapse removed, such as stone in the bladder, 
a stricture in the urethra, or an operation for phimosis, these 
patients will get well without an operation. But where all 
such 'have been tried, or there is no existence of diseases 
which cause prolapse, then it is necessary to think of more 



488 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

positive means of cure. The method of applying ligatures to 
sections of the mass, after the same manner as the operation for 
haemorrhoids, has been practiced and favorable reports made, 
but the plan has been more or less decried by some authors. 
Dr. Beane, of New York city, reported a cure of a large, com- 
plete prolapse in a woman of forty-two, by applying the clamp 
successfully to the tumor at four points, inclosing at each 
point a fold of mucous membrane an inch and a hal f long, 
cutting off half the tissue projecting beyond the clamp and 
cauterizing the remainder. I am favorably inclined to this 
method of curing cases of prolapsus ani, which can not be 
cured by palliative means, and my faith in this method has 
arisen from the good results that have followed these oper- 
ations in my hands. Whenever, therefore, I see a case of 
simple prolapse of the bowel, and am satisfied that no peri- 
tonaeum is included, my rule is to do as follows : I have the 
patient's bowels freely moved the evening before and on the 
morning of the operation ; I have an enema of hot water 
given. I then direct that, during the passage of the water, 
the patient is to strain violently, which will bring down the 
prolapse, and in this condition he is to lie upon the table. In 
the majority of these cases the operation can be done without 
an anaesthetic, and I prefer to do so for the reason that the 
sphincter muscle will aid me very materially in restraining the 
prolapse and preventing it passing back into the bowel, where, 
under an anaesthetic, the bowel slips back with easy effort. 
Having shaved the parts and washed them thoroughly with 
the bichloride solution (1 to 3000), with my pile-clamp I catch 
up a section of the gut, transfix it with a needle, and tie 
tightly on each side. I then cut off the mucous membrane 
close to the ligature. This is repeated several times, going 
round the circumference of the gut if necessary. I then dust 
the exposed parts freely with iodoform, and gently push it back 
into the rectum ; then placing a pad over the anus and apply- 
ing a T-bandage, the operation is complete. I do not allow 
the bowels to move for three days, when an aperient is given 
and an enema, after which very little treatment is necessary. 



PROLAPSUS ANI. 489 

Several years ago I reported to the Kentucky State Medi- 
cal Society an operation for prolapse in a gentleman fifty- 
five years old, after this manner, including at five different 
points as much as two inches of the mucous membrane, cut- 
ting off most of the tissue above the ligature, dressing anti- 
septically, and finishing in the manner I have described. 
The operation was successful, and no return has ever been 
noticed. 

If I were restricted to one local application for a simple 
prolapse of the rectum I would take carbolic acid, although I 
have said that the use of any strong acid is to be deprecated 
in these cases. I have no doubt that many cases of stricture 
of the gut have resulted from the application of fuming nitric 
acid. At a meeting of the Therapeutical Society {Gaz. Heb- 
domadaire) Dr. Ferraud related the case of a lady, thirty-five 
years of age, who during three years had suffered from rec- 
tal and hemorrhoidal prolapsus to the extent that she could 
not walk around her room without a tumor almost as large as 
a fist descending, inducing most acute suffering. The tumor 
could be reduced while lying in bed by means of a prolonged 
and very painful taxis, which had to be repeated after every 
stool. Having tried all the usual remedies in vain, Dr. Fer- 
raud gave a subcutaneous injection of ergotin, depositing one 
gramme (twenty centigrammes) of a solution composed of 
glycerin and water, of each fifteen parts, and alkaline hy- 
drated extract of ergot, two parts, in the ischio-rectal fossa, 
beside the hemorrhoidal projection. Considerable ameliora- 
tion resulted, and three other injections were given at inter- 
vals of twenty days, ten days, and a month, with the result 
of effecting a cure. The patient was seen six months after- 
ward, and it was found that the prolapse was not reproduced 
in walking, going up many flights of stairs, etc. 

It appeared to me, when reading this report, that the 
natural thing to do would have been to operate on this 
woman for haemorrhoids by the ligature, and she would have 
been promptly cured of prolapsed haemorrhoids and prolapsus 
recti. Granting that the ergotin injection would remedy the 



490 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

prolapsus, what could be the necessity for drawing a lot of 
hemorrhoidal tumors above the sphincters and keeping them 
there ? To have cured them, as well as the prolapsus, would 
have been pleasant to the patient to say the least of it. When- 
ever large haemorrhoids exist and protrude from the rectum, 
prolapsus of the gut naturally follows. If an operation is 
done for piles, the prolapse will disappear. The attention of 
the profession was first called to the treatment of prolapsus 
ani by the subcutaneous injection of ergotin in a paper read 
before the French Academy of Medicine by M. Emile Vidal, 
in which he reported three cases successfully treated by this 
method. The first was a man aged thirty-nine ; the length of 
time prolapse existed, eight years. Total number of injections, 
twenty-two. Four years and no return. The second patient, 
female, aged sixty -four, cured after twenty-four days' treat- 
ment, and the third patient was cured by six injections. The 
solution used was Bon jean's ergotin, fifteen grains, and cherry- 
laurel water seventy -five minims. Two days were usually 
allowed to intervene between injections ; the needle inserted 
at a distance of one fifth of an inch from anal orifice. Acute 
pain always followed, accompanied by contraction of the 
sphincter, which lasted several hours. Spasm of the neck of 
the bladder and retention of the urine frequently followed. 
In no case, the report says, was local inflammation or abscess 
caused by the ergotin. The amount injected was usually ten 
or twelve drops of the preparation named. 

My experience with this remedy has been so very unlike 
that recorded here that I beg to give it. Acting upon the 
suggestion of Vidal, I tried the injecting plan of ergot in two 
cases of prolapsus ani. The following is a brief history : 
Mrs. A. D., aged fifty- two, had prolapsus for seven years. 
Invariably comes down at stool during the act of defecation. 
Her general health was much below par. No special diathe- 
sis. Complains of pain in the back extending down the legs. 
Has a mucous discharge from the rectum, occasionally tinged 
with blood. It is so great at times as to be called by her a 
dysentery, and has been so prescribed for by several physi- 



PROLAPSUS ANI. 



491 



cians. In her case I made sixteen injections with the prepa- 
ration suggested, using glycerin instead of cherry-laurel 
water. Allowed two or three days to intervene between in- 
jections. Was injected each time at my office, walked home, 
and never ceased her household duties. The result was as 
follows: After the third injection she expressed herself as 
greatly relieved of the pain in back and legs ; also states that 
the tumor is not so large. After the tenth injection the size 
of the tumor had perceptibly diminished. Up to the fifteenth 
injection she had not complained of any pain at the time of 
injecting, or thereafter. No contraction of the sphincter or 
spasm of the bladder. After injecting the sixteenth time I 
missed her from my office for several days, when I was sum- 
moned to her residence, and found her suffering with a large 
rectal abscess. This was freely opened and several ounces 
of pus escaped. It got well rapidly and left no fistula. The 
patient appeared at my office six weeks afterward, saying 
that she had never had any return of the prolapsus since the 
last injection. Two weeks afterward, making eight weeks 
since treatment, she again came back and informed me that 
upon going to stool that morning the bowel descended as 
much as formerly. 

The second patient was a young man in robust health. 
Only eight injections were given when local inflammatory ac- 
tion was excited. I feared the result, as experienced in the 
first case, and discontinued the ergotin treatment. Whether 
the abscess was caused in the first patient by allowing her to 
pursue her daily avocations is a question. Be that as it may, 
it appeared at or near the point of injection. That ergotin 
could produce inflammatory action it is reasonable to sup- 
pose, and if an abscess occurs even occasionally, and not as a 
rule, the treatment could not be recommended. The method 
is slow in detail, and, as Yidal says, accompanied by much 
pain and distress. That the result of such treatment is satis- 
factory can not be borne out in fact. Therefore, for the above 
reason, and the experience that I have had with the agent, I 
certainly can not recommend the method. I would call at- 



492 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

tendon especially to three points in the report of my cases : 
1. The complete absence of acute pain. 2. No contraction of 
sphincter muscle or spasm of the bladder. 3. Abscess and 
local inflammation did ensue. 

I ascribe the absence of pain during the injections or fol- 
lowing them to the fact that the point of the needle was in- 
serted farther out toward the ischio-rectal fossa than was 
done by Vidal, thereby escaping the muscular fibers of the 
sphincter. To this reason also was the freedom from a con- 
tracted sphincter, spasm of bladder, etc., accredited. For 
what reason my patients and not those of Vidal suffered local 
inflammatory action, and in one instance ending in abscess, 
I can not account. 

This plan of treating prolapsus ani by ergotin, although 
advised for a time w T ith much vigor, has fallen into disrepute, 
and to-day there are a very few that give it mention at all. 
There are other plans that meet the indication better, and 
should be adopted. Fortunately, the disease is rare so far as 
the complete variety is concerned, and the simple variety is 
mostly confined to children, and will get well under special 
directions without an operation. 



CHAPTER XXI. 

PRURITUS ANI. 

Of all diseases of the rectum or anus, pruritus ani is the 
most intractable one. If a patient presents having a well- 
defined case of internal or external piles, a polypus, a fissure, 
an irritable ulcer, or a fistula in ano, we can safely say to 
him: "If you will submit to treatment, we can promise you 
that in a very short time you will be entirely relieved." It 
is not so with patients suffering with pruritus ani. It taxes 
all the energy and thought of the physician to fight success- 
fully this trouble. The patients do not complain of any 
pain, but will frequently say to you that they would rather 
have a painful disease ; indeed, they will submit without 
hesitation to any pain that you can inflict upon them that 
looks to their relief at all. I have had a number of such 
patients to say to me that pain was really a relief to them. 
For instance, in making an application of iodine, carbolic 
acid, and other substances which excite pain, they would not 
complain at all. 

JEtiology. — As regards the aetiology of this disease there 
has been much discussion. Some contend that it is a local 
disease, others that it is a constitutional one. Some say that 
it is due to the reflexes ; many ascribe it to the habits of 
the patient ; others believe it is strictly neurotic. I am sure 
that all of these causes more or less play a part in the pro- 
duction and continuation of the disease. If it be a constitu- 
tional affection, it is aggravated and kept up by the eternal 
effort of the patient to scratch himself. If it be a local dis- 
ease, like all other inflammations, it is aggravated by any- 



494 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

thing that disturbs the general constitution. Now, I know 
that some authors writing on this subject classify pruritus 
ani as a symptom only of some other disease. I am sure 
that this is a mistake. Kelsey says: ''Pruritus ani is gen- 
erally a symptom of some other disease, such as haemor- 
rhoids or eczema, but it is often present in a marked degree 
when no cause for its existence can be discovered." There 
can be no doubt that this statement can be borne out by facts 
in so far as the quotation indicates that pruritus ani exists 
as a symptom along loith haemorrhoids or eczema, if pruritus 
can be called a symptom, and not a disease per se. But in 
searching for the true aetiology of the disease, we are at once 
set back in our opinion by the latter clause of the quotation, 
"but it is often present in a marked degree when no cause 
for its existence can be discovered." Now, if we are just 
simply to deal with itching at the anus as a symptom, it 
should receive no consideration as a disease in fact, but 
instead, when treating of such subjects as haemorrhoids, ecze- 
ma, etc., we should say that when these diseases are cured 
the symptom or symptoms will disappear. Some authors go 
so far as to say that although pruritus ani may exist to a 
marked degree when associated with haemorrhoids or other 
rectal disease, just so soon as the haemorrhoids are oper- 
ated upon and are cured this symptom will disappear. This 
has not been my experience at all, but, on the contrary, in 
every single instance where pruritus existed to any degree, 
coincident with the haemorrhoidal disease, it was found in 
just as bad form after the patient was cured of haemorrhoids 
as it was before the operation. When we consider the 
changes that take place in pruritus, it can be easily under- 
stood that this would be so. The skin becomes thickened 
and parchment-like ; is thrown into heavy and nearly in- 
durated folds ; a pathological condition not only exists in the 
nerves supplying the integument, but in the integument it- 
self. From the act of scratching there is a great loss of the 
natural pigment over the parts affected. The skin changes 
color and becomes of a dull, whitish appearance instead of 



PRURITUS ANI. 495 

the natural one. There may be an exudation from this whole 
surface, consequently a moisture, or it may be of a dry 
parchment character ; therefore I can not believe with Kel- 
sey that "pruritus is often a symptom of internal haemor- 
rhoids, and is easily and effectually cared by their removal." 
Again, it is often a symptom or complication of a iistula with 
a small external opening, such as may be overlooked in a 
cursory examination, and is cured by the ordinary opera- 
tion and the consequent cessation of the discharge upon 
which it depends." Suppose we have the changed condi- 
tion of the skin of which I have spoken in a case where 
there is no discharge of any kind from haemorrhoids, fistula, 
or any other diseased condition. Why is it then so intracta- 
ble and hard to cure? Now, if a discharge has been the 
cause of this condition, you may stop the discharge, but the 
condition remains. I would ask, Are the two conditions the 
same ? If it is true that the pruritus will disappear so soon 
as the hemorrhoid is cured, then it was in fact only a symp- 
tom ; but if we find the same thing existing with the patho- 
logical changes in the cuticle that I have mentioned, then it 
is a disease in fact, and must require special consideration 
and treatment. It is either a disease or simply a symptom 
of disease. Which is it? Among the diseases mentioned 
that may produce these symptoms are disorder of the digest- 
ive system ; constipation ; disorder of the liver ; intestinal 
worms ; disease of the kidneys ; disease of the uterus or ova- 
ries ; stricture of the urethra ; stone in the bladder ; haemor- 
rhoids ; fistula ; cold ; mental diseases ; habit, such as drinks 
ing, smoking, etc. It reminds one very much of the reply 
that the old country doctor gave the consultant when he 
was asked what he gave a prescription for which contained 
so many ingredients. He replied: "If one remedy doesn't 
hit the disease, perhaps another will." In applying it here 
we might say that if pruritus was not caused by one of these 
many different diseases, perhaps it was caused by the other. 
I believe that an explanation of this trouble can be found 
in the distribution of nerves to the lower part of the rectum. 



496 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

The inferior hemorrhoidal nerves, which give the principal 
nerve supply to the integument around the anus, also send 
branches to the lower inch of the mucous membrane of the 
rectum. In cases of pruritus ani the greatest itching is ob- 
served to be just within the anus, as this nerve supply would 
seem to indicate. Now, I believe that pruritus ani is a disease 
of local origin, implicating the terminal nerves, and that it is 
kept up by many things, especially by the reflexes ; therefore, 
if there be a diseased condition of the bladder or genital or- 
gans, excessive sexual indulgence, great mental exertion or 
excitement, stomach troubles, malarial poison, use of tobacco 
or stimulants, the disease will be aggravated through the 
general system or by direct reflexes. As to local causes we 
can mention parasites — as u pediculi" and "thread-worms," 
the use of hard or printed substances for detergent purposes, 
or the production of an abrasion from any cause, as a margi- 
nal sinus, a small fissure and eczema can be so classed. These 
produce not only an irritation but an excoriation, and the 
nerves distributed here are at once affected. I have seen 
many cases of severe pruritus of the anal region in men and 
women who were otherwise perfectly healthy. In looking 
over my record book I am satisfied that the majority of my 
cases suffering from this disease did not have other rectal 
disease, and I am equally sure that the majority of cases that 
I have treated and operated on for internal haemorrhoids had 
no pruritus ani. So well persuaded am I of this fact that if 
I had never read anything concerning the symptoms of hgem- 
orrhoidal disease I would not class pruritus as a symptom 
at all. 

Fothergill says : " Pruritus ani, with or without eczema, is 
sadly common in liver indigestion, and is an outcome of blood 
poisoning by the products of indigestion." That liver indi- 
gestion may produce an itching at the anus I have no doubt. 
That it causes a well-authentic case of pruritus, involving the 
pathological changes in structure which we have noticed. I 
do not believe. 

We have stated that we believe pruritus to be a local dis- 



PRURITUS ANI. 



497 



ease and must be so treated. In other words, I do not be- 
lieve that, after pruritus ani is established, treating the organ 
which caused the affection will cure the pruritus, whether 
it be kidney disease, liver disease, or what not. I do not 
wish to be understood as saying that the terminal nerves 
around the anus and rectum can take on disease without a 
cause, for there may be many local conditions which would 
produce the disease. For instance, if the portal circulation 
is interfered with, and the blood is held in the hemorrhoidal 
veins, a congestion results which, after a while, ends in a 
varicose condition of the blood-vessels, and eventually a 
good-sized hemorrhoid results. Now, this congestion and 
interference with the blood-supply of the rectum, of course, 
also interferes with its nerve function, but it has been 
a local change. If the epidermis is scratched off at the verge 
of the anus, the filament of a nerve is exposed, and the 
excitation of it produced by scratching keeps up the itching. 
The same can be said of the excitability here of the terminal 
nerves by the presence of thread-worms or the existence of a 
small fissure or a marginal sinus. After the condition is estab- 
lished, and we not only have itching but the disease, then I 
am fully persuaded that anything which affects the general 
nerve system will be reflected here. I am satisfied that I 
I have seen cases of pruritus ani aggravated by drinking cof- 
fee or whisky. I can recall one or two instances where the 
smoking of several strong cigars would cause the itching. 
The worry that business and professional men are sometimes 
subjected to will increase the symptom, but I do not be- 
lieve that either one or all of these can originate a case of 
pruritus ani. 

Symptoms. — I hardly think that a true case of eczema, either 
acute or chronic, should be designated pruritus. Although 
eczema will cause the itching sensation referred to, yet, if seen 
in its incipiency, it is more easily cured than a case of pruri- 
tus per se. Pruritus is not attended by pain unless some 
fissure or abrasion is encroaching upon the external sphinc- 
ter muscle. There is really but one symptom of the disease, 

32 



498 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

and that is itching — that terrible, everlasting, maddening, 
distressing itching. There is sometimes an exacerbation 
of a few hours, and often these patients are not troubled 
much through the day, but at night, after they retire and 
get warm in bed, the horror begins. I have had more than 
one patient tell me, suffering from this disease, that if it 
were not for their family they would commit suicide, and 
one patient, to my knowledge, went crazy with the affection. 
Therefore, although looked upon often by physicians as a 
trivial affair, it is a very serious one and deserves our hon- 
est attention. The more the local parts are irritated by 
scratching, the worse the condition is, and yet they can get 
a surcease from their trouble, for a few moments at least, 
by the effort of scratching. These patients frequently get 
in the habit of taking opium to produce sleep, and yet it 
is a well-known fact that opium increases the trouble. We 
implore these patients not to scratch themselves, and yet 
it would do just as well to ask the man dying of thirst 
not to take a cool drink of water if it were within his 
reach. 

Treatment. — I believe that the treatment should be applied 
principally to the local condition, and yet, unless the patient 
gives his consent to allow you to observe him for as long time 
as necessary, it is of no use to begin. Of course we do not see 
these patients until the disease is established, and, as I have 
already said, believing that habit, etc., has much to do in 
keeping up the affection, it is proper to say to the patient be- 
fore you begin treatment that he must leave off such things 
as alcohol or malt liquors, the use of tobacco in any form, 
excessive venery, mental worry, if he can, rich and spiced 
food, and live altogether a temperate life. In giving these 
instructions once to a patient, he admitted that he was in the 
habit of getting on periodical sprees. I said, of course, that 
he must stop them or I could not cure him. I had him under 
observation for a number of months, and at last he quit coming 
to the office, but appeared again after awhile. During this 
interim his wife came to me and informed me that her hus- 



PRURITUS ANI. 499 

band had been on a big drank, and plead with me, for the 
sake of her and his children, that I would do something to 
frighten him into stopping drink. I told her that I would 
think over the matter, and if I could do anything looking to 
that end I certainly should ; but I confessed that I was at my 
wits' end. When he again came to the office he remarked 
that he had simply dropped in to tell me that he was entirely 
cured. So I was confused as to the manner in which I should 
approach him to make an impression on him in the matter of 
drink, but asking him to lie upon the table, which he con- 
sented to do after protesting, I uttered a hurried exclamation, 
and he turned his head quickly and said : " What is the mat- 
ter?" I answered: "You've been drunk." He asked who 
told me so. I replied that it was not necessary to be informed 
of the fact, as I saw plain evidences that his disease was com- 
ing rapidly back again, and that it would ruin him for life if 
he did not quit the habit. He evidently believed me, for he 
swore that he would never take another drink. Whether my 
deception played its part I have never heard. 

The patient suffering from pruritus ani presents himself 
asking for some remedy that will relieve the terrible itching 
to which he is subjected, especially at night. As we have 
already stated, this terrible itching usually begins just after 
the patient has ensconced himself in bed ; therefore, outside 
of any treatment except palliative, we should direct the pa- 
tient as follows : Before retiring, the parts should be bathed 
in as hot water as can be endured. Then, after carefully 
drying, he should be instructed to apply the following : 
9 Campho-phenique 3 j ; 

Aquae dest 5 j. M. 

With this he is to bathe the parts freely and often if 
necessary. A very good prescription under these circum- 
stances is the following : 

9 Chloral hydrat 3 j ; 

Gum camphor 3 ss. ; 

Aquae des., 

Glycerin aa 5 j. M. 



500 DISEASES OP THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

This preparation to be applied as frequently as desired. 
It may be found, in addition to any local application, that it 
will be necessary to give some hypnotic to produce sleep. 
In this event it is best to avoid the administration of any 
opiate, and, as a substitute, I have found the following to 
be of service : 

5 Sulphonal gr. xl. 

Make four capsules. 

Sig. : Take one and repeat every hour if necessary. 
Allingham recommends a chloroform ointment made by 
rubbing together one drachm of chloroform and an ounce of 
lard or cosmoline, and repeat the application during the night 
if necessary. It will be found for the purpose of producing 
sleep that the remedies will be often changed and must be con- 
sidered as only palliative. The treatment directed to a cure 
must be entirely different from this. As has been indicated, 
a pathological condition exists, a change in the natural struct- 
ure of the part, and therefore prompt attention must be given 
to this condition. It will be observed in the treatment of these 
cases that an unnatural condition of the skin exists ; in other 
words, a scarf skin, which must be destroyed. Any remedy 
that is applied that accomplishes anything less than the de- 
struction of this new formation will be found to be of no per- 
manent benefit ; therefore we should look to something more 
permanent in the treatment. There are several agents which 
will effect the destruction of this scarf skin. Among these 
may be found tincture of iodine, pure carbolic acid, campho- 
phenique, etc. It is utterly useless to prescribe remedies 
that are antipruritic without first destroying this new forma- 
tion of skin. Therefore I would suggest that in a patient 
where the condition that I have described exists, the whole 
surface should be coated with the pure tincture of iodine, 
said application to be used every two or three days until the 
object has been accomplished, or it may be, for reasons which 
the case will indicate, that the carbolic acid is to be preferred. 
In this instance I wrap a probe with surgeon's cotton and dip 
it in pure acid, separate the folds around the anus and apply 



PRURITUS ANI. 501 

freely between each and all of them, then over the entire sur- 
face. This can be repeated on the third or fourth day. The 
campho-phenique is an admirable substitute for either one of 
the other remedies, applied in the same manner. It will be 
noticed, after a sufficient number of applications of either one 
of the remedies, that the cuticle will begin to peel off and 
leave a new base. Some inflammation will be excited, but 
this, of course, should not be noticed. After its entire and 
thorough destruction, other remedies can be used of a milder 
type. Of course these are innumerable, but I have learned to 
rely upon a comparative few. Among those that I like best 
will be found the following : 

Ij£ Bichlor. hydrar gr. iv ; 

Vaseline 1 j. 

M. Sig. : Apply. 
Or what is more suitable to the majority of cases is : 

Jfc Hyd. chl. mit 3 ij ; 

Vaseline § j. 

M. Sig. : Apply. 
Or, 

Ij£ Oxide zinc § j ; 

Balsam Peru 3 j. 

M. Sig. : Apply. 
The following is a favorite with Allingham : 
5 Liquoris carbonis detergens 
(Wright's), 

Glycerinse aa § j ; 

Pulv. zinci oxidi, 

Calamin. prep aa § ss. ; 

Pulv. sulph. precip 3 ss. ; 

Aquae purse ad 5 vj. M. 

A favorite prescription of mine is : 

5 Menthol 3 j ; 

Mur. cocaine gr. xx ; 

Alcohol, 

Aquae dest aa § j. M. 

This is to be applied by means of cloth. 






502 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE, 

Dr. Bulkley recommends the following : 

9 Ungt. picis 3 iij ; 

Ungt. bellad 3 ij ; 

Tinct. aconit. rad 3 ss. ; 

Zinc oxidi 3 j ; 

Ungt. aquse rosae 3 iij. M. 

An ointment of chloral and camphor, a drachm of each to 
the ounce, is said to be very effectual in allaying itching. 
But every case of pruritus ani must be considered an indi- 
vidual one and the remedies applied accordingly. If this 
changed condition in the nerve distribution has been brought 
about by constipation, then constipation must be relieved in 
the manner as suggested in the chapter devoted to it. Under 
such a condition of affairs nothing will be found to act so 
admirably as injections of cool or cold water ; but the other 
rules, as laid down for treatment of constipation, must be ob- 
served. 

If there exist such symptoms as indicate hepatic disturb- 
ance, purgation is not necessary ; but some remedy or reme- 
dies should be given looking to the increase of the natural se- 
cretions. I have found the following plan to be of service in 
such cases : Direct the patient to buy a dozen fresh lemons 
and each night to squeeze the entire juice from one lemon into 
a glass, then fill the glass with water and drink it, without the 
addition of any sugar. This to be repeated until the twelve are 
taken. Or, in the drinking habit, it will be found necessary 
to administer some remedy for its cholagogue effect. There is 
none better than calomel, taken in broken doses. As a sub- 
stitute for this, however, under certain conditions, I am in 
the habit of prescribing, viz. : 

5 Bichlor. hy drar gr. j ; 

Tinct. cinchona 5 iv. 

M. Sig. : Take a teaspoonf ul three times a day. 

This preparation will be seen to have a mild and yet a de- 
cided effect upon the secretion of the liver. 

If thread-worms are observed to be the cause of this 
trouble, of course remedies should be adopted which will 



PRURITUS ANI. 503 

eradicate them. I have found that injections of cod-liver oil 
usually accomplish this purpose. If it is necessary to medi- 
cate the oil, it can be done with lime water, carbolic acid, or 
campho-phenique, one drachm to eight ounces of the oil. 
Other remedies used are tincture of iron, turpentine, chloral, 
etc., made in proper solution. Van Buren said in his work that 
in the beginning of his practice he was in the habit of using 
sulphurous acid as a last resort in pruritus ani, where he 
suspected a vegetable instead of an animal parasite, and that 
his experience taught him to use this acid first instead of last. 
It can be diluted with water, equal parts, but I am in the 
habit of applying it pure in cases where I suspect the trouble 
to be parasitic. I have also found that an application of pure 
carbolic acid destroys this vegetable parasite. If this disease 
of pruritus ani has for its origin a small fistulous sinus, it 
must be sought out and divided. If any piles, polypus, fis- 
sures, etc., exist, they should be operated on. In women it 
should be noticed whether there is any disturbance of the 
womb or the vagina, as will be indicated by the discharges. 
If so, all these should be attended to. But more espe- 
cially should the reflexes be traced. The man should be 
questioned about his habits, and if there is a suspicion of 
stricture of the urethra he should be referred to the proper 
specialist. If it is believed that the woman has ovarian 
tube or womb trouble, she should be referred to the gyne- 
cologist. Sometimes it will be a difficult thing to trace out 
the proper reflex in these cases, but it is worth our attention 
to try to do so. At the same time it must be remembered 
that we have had established here a disease within itself, 
and nothing less than a persistent course of treatment will 
effect a cure. It may be that habit has something to do in 
keeping up the trouble, therefore the use of alcohol or malt 
liquors, tobacco, coffee, tea, stimulating food, late hours, 
excessive eating — all should be interdicted. It is well, in be- 
ginning a course of treatment of these patients, to have the 
intestinal tract entirely cleared. Hence it is very well to sug- 
gest to these people the taking often of some of the mineral 



504 DISEASES OP THE RECTUM, ANUS AND SIGMOID FLEXURE. 

waters, say Saratoga, Carlsbad, French Lick, or any other 
good aperient water that will accomplish the purpose. The 
patient should be especially instructed not to sleep on a 
feather bed, but on a mattress. The cover should never be 
excessive and the room not overheated. Constitutional 
remedies are frequently advised for this class of patients, 
such as cod-liver oil, quinine, strychnine, arsenic, and sali- 
cylate of soda ; also pilocarpine and jaborandi are said to be 
beneficial in some cases. I have tried many drugs looking 
to their constitutional effect, and, in the majority of cases, 
must say that I have obtained no good whatever from them. 
I believe that the practice of frequent bathing — not only the 
hot- water bath but the Russian bath — is of service in these 
cases. To accomplish the entire destruction of the patho- 
logical structure around the anus in pruritus ani, it is pro- 
posed by the French that it be reduced to a surgical opera- 
tion in lieu of removing it by medicine. Therefore the plan 
has been adopted of placing the patient under the effect of 
an anaesthetic and scraping the entire scarf skin away. This 
looks to me to be extremely plausible. For, indeed, all of our 
efforts at a cure of this formidable disease can only succeed 
after this skin is destroyed. Its destruction by medicine is a 
slow process, and I believe if this suggestion is followed, 
to scrape it away by means of a scoop while the patient is 
under the effect of ether, that if this alone does not accom- 
plish a cure, the medicine applied afterward will be more sure 
to take effect. I should mention, before closing the chapter, 
that some authors have praised very highly the use of elec- 
tricity in this trouble. I can not believe that electricity is 
anything but palliative, but it is said by some to have a cura- 
tive effect. It may be used either in the form of the galvanic 
or faradic current, applying it to the surface as strong as the 
patient can bear, the feeling of the patient being the guide. 
In my experience, the galvanic current has proved of more 
service than the faradic, but others have reported the reverse. 
I can, however, only recommend it as a palliative measure. 
Allingham recommends — when the irritation of pruritus 



PRURITUS ANI. 



505 



is so great that the patient is quite worn out for want of 
rest — the introduction into the anus at bed -time of a bone 
plug, shaped like the nipple of an infant's feeding-bottle, 
with a circular shield to prevent its slipping into the bowel. 
The nipple should be about an inch and a half in length and 
as thick as the end of the forefinger. He says that it is most 
efficient in preventing the nocturnal itching, and that a good 
night's rest is almost sure to result from its use. In explana- 
tion of this he says : "I presume that it benefits by exercis- 
ing pressure upon the venous plexuses and filaments of nerves 
close to the anus." 

This corresponds to my idea of the pathology of the dis- 
ease. But, after trying every known remedy and measure, 
the physician may be baffled in his efforts to cure this pe- 
culiar affection. The patients that are with him to-day will 
drift to another to-morrow, and he need not be surprised to 
hear of them in the hands of quacks before they get through. 
It is a singular fact, and yet a true one, that after trying 
many remedies the physician or patient will stumble upon a 
very simple one which will give relief. I remember once to 
have treated a robust and healthy Irishman for an intolerable 
itching of the anus for a number of months, after which time 
he disappeared, and I did not see him again for a year, when 
he told me that my remedies had done him no good, and some 
old woman had advised him to purchase five cents' worth of 
calomel and rub it up with just as much lard as would hold 
it conveniently, and apply it. He attributed his whole cure to 
this prescription, and gave me no credit for what I had done. 
Divulsion of the sphincter muscle is sometimes of great serv- 
ice in treating cases of pruritis ani. 



CHAPTER XXII. 

IMPACTED FAECES. 

The common impression is, I am sure, that when the 
term " impacted faeces" is used, the location is set down as 
being in the rectum. Allingham says: "The result of an 
attack of constipation may be a collection of clayey faeces, 
formed in the caecum or in any part of the colon ; but the 
term impaction is generally used when the accumulation 
takes place in the pouch of the rectum, immediately above 
the internal sphincter muscle. This is its most frequent situ- 
ation, and here a very large deposit, more or less globular in 
shape, is often found." 

Now, we have tried to demonstrate in this work, in dealing 
with the anatomy of the intestines and the subject of consti- 
pation, that the rectum proper was never intended to be a 
natural receptacle of the faeces, and a study of the subject 
reveals the fact that the deposit there is only temporary. 
Therefore I think that it is frequently overlooked that the 
seat of impaction is the sigmoid flexure and not the rectum. 
I do not wish to be understood as saying that an impaction of 
faeces is not often found in the pouch of the rectum ; but I do 
mean to say that if it is not found there, our search should ex- 
tend higher up into the colon. There are therefore three dis- 
tinct places where we should look for impaction of faeces— 
viz., the caecum, sigmoid flexure, and rectum. As the ac- 
cumulation of faeces, or any other obstruction of the caecum, 
is out of the scope of this treatise, we will not refer to it ; 
and, as in another chapter we have spoken of impaction of 
faeces in the sigmoid flexure, we will confine our remarks 
here to the accumulation of the same in the rectum proper. 



IMPACTED FAECES. 507 

I have met with this condition in persons of middle life, 
in the aged, and in the young. Indeed, in this modern day, 
when a rush is made after an education and all the rules of 
health thrust aside, it is natural to suppose that we would 
find school children, especially girls, suffering from obstinate 
constipation, which is the precursor of impaction. It occurs 
in my practice repeatedly to be called to young girls who 
have never been instructed in the ordinary health rules, and 
who scarcely know that they possess a rectum, and certainly 
are not aware of the fact that their bowels should move at 
stated intervals ; and, as a consequence, suffer from an impac- 
tion of faeces. Allingham says : "The cause of the accumu- 
lation I believe nearly always to be primarily a loss of power 
over the muscular coat of the rectum." Now, I do not believe 
that this is the prime cause, except in a certain class of pa- 
tients. In the aged, where the muscular coat has lost its 
tone, I believe this may be true, or in the pregnant woman, 
where the child's head during a long protracted labor has 
pressed upon the bowel, such a condition may exist. But 
ordinarily, and in the majority of cases, I believe that this 
rule is reversed ; that the impaction causes the loss of to- 
nicity in the muscular coats, and, as a result, we have the 
impaction of faeces. The sphincter muscle plays a wonderful 
part as an adjunct in this trouble. Whenever it becomes irri- 
table the constant spasm of its muscular fibers prevents the 
normal evacuation of the bowels, and consequently many 
efforts may be made to evacuate it, but to no avail. There- 
fore, in cases of impacted faeces it will be found that this 
spasm of the sphincter exists, not as the cause of the impac- 
tion, but as a result of it. I have known these cases to be 
treated for every known rectal affection before a positive 
diagnosis was made, and yet if it is a real case of impaction 
of faeces in the rectum, the simple introduction of the finger 
will clear up all doubt. I will only give one case as pertinent 
to the truth of this statement. 

Case. — A physician telephoned me to meet him at a busi- 
ness man's residence on a certain morning. I complied with 



508 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

his request, when he told me that the patient was suffering 
from some form of piles, and wished me to examine him. In 
going into the patient's room, I was informed that he had been 
in bed for a week. That he had a desire to go to stool often, 
and that after evacuating his bowels he did not feel relieved ; 
that he had considerable straining at stool, with some dis- 
charge of blood, and that his actions were liquid. Examining 
his parts externally, I could find nothing pathological except 
a fullness of the veins at the outlet of the rectum. Anointing 
my finger and introducing it, I at once detected a large, oval 
mass that appeared very solid, and could be only slightly 
indented with the finger. In sweeping my finger around it, 
I detected that it was an impaction of faeces which had evi- 
dently existed for a long time. Upon questioning the patient, 
I found that he did not remember when he had had a well- 
molded action, and yet he was under the impression that he 
was then suffering at that time from a diarrhoea. I advised 
that the patient be put under the influence of chloroform, 
which was done, when I divulsed the sphincter muscles freely, 
and by the aid of a scoop removed or delivered this entire 
mass. 




Scoop for the removal of fseces. 

It will be seen from this case that the symptoms of impac- 
tion are sometimes very obscure. Indeed, it may be confound- 
ed, as I have intimated, with any other rectal affection. If it 
is allowed to go on for any length of time the patient becomes 
melancholy, a bad color is taken on, and flesh is lost rapidly. 
An irritability of temper, nervousness, etc., supervenes, and 
it is no wonder that these patients are thought to be suffering 
from a malignant disease. It is a most wonderful cause for 
the reflexes ; hence these patients will be found complaining 
of pain in the back, in the abdomen, down the thighs, diffi- 
culty in micturition, etc. When their symptoms are described 
to the physician, and he ascertains the fact that no solid ma- 



IMPACTED FAECES. 



509 



terial has been passed for some time, he naturally infers that 
the patient suffers from stricture, or, if some of the mass has 
been passed in a solid way, it may be in the form of little bits 
or of a tape-like character, and these are symptoms which 
confirm the physician in his opinion of stricture. It must be 
remembered that such actions are usually the result of, and 
controlled by, an irritable sphincter muscle. Where an im- 
paction has existed for a great while the patient has morning 
vomiting, a loathing of all food, a painful thirst, night- sweats, 
a peculiar barking cough, and, consequently, it is often sup- 
posed that he is going into a decline, perhaps from phthisis. 
I have tried often to detect these tumors by palpating over 
the abdomen, but I must confess that it is a difficult thing 
to do, whether the impaction exists in the caecum, trans- 
verse colon, or the sigmoid flexure. It has been suggested 
that in cases of impacted faeces the anus is nipple-shaped, 
and the sphincter muscle is tightly contracted and almost as 
hard as a piece of wood. The size of this mass in the pouch 
of the rectum may vary from that of a lemon to that of the 
foetal head. It is movable, and therefore allows of a liquid 
action passing around it. I think the diagnosis is made clear 
in such a case by the introduction of the finger, for it can 
only be confused with a tumor, and the proper manipulation 
will show that it is movable and has no attachments ; this, 
together with the peculiar doughy feel, will make out the 
diagnosis. 

Treatment. — The first thing to be done under these circum- 
stances is to break up the faecal mass. This can not be done 
without the aid of an anaesthetic. There is no preparatory 
treatment necessary except to have the patient do without 
the preceding meal. Having him well under the influence of 
the anaesthetic, we should forcibly divulse the muscle. It will 
be found that half-way measures here will not do. The 
spasm of the muscle must be overcome, and that can only be 
accomplished by a thorough dilatation. But to those who 
have never removed a faecal mass it will be found a difficult 
thing to do so. It will not by any means fall out of the rectum 



510 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



when the sphincter is dilated. We will be compelled to 
bring to onr aid some instrument besides our linger. In doing 
this operation ouce in the country when I was without my 
regular scoop, I called for and used a medium-sized iron 
spoon, and I was persuaded that it was one of the very best 
instruments that could be used for the purpose. Some sub- 
stitute a lithotomy scoop, but anything of the kind that 
meets the approbation of the surgeon can be used. Some 
care must be taken not to injure the bowel in our effort to 
scrape out the mass. After we are satisfied that it has all 

been removed, an irrigation of hot 
water should be used freely to the 
surface of the bowel. In removing 
the mass from womeu, it is suggested 
that by introducing two fingers of the 
left hand into the vagina, and by 
pressing backward, we can fix. the 
mass against the sacrum, so that it 
can not slip up the bowel. An after- 
treatment of these patients is abso- 
lutely necessary ; for it makes very 
little difference whether the atony of 
the muscular coat is primary or sec- 
ondary, an effort must be made to 
restore its tonicity. For a few days, 
therefore, I advise injections of hot water into the bowel. 
Then I have them discontinued, substituting tepid water, 
gradually increased to a cold temperature. It is sometimes 
necessary to medicate this water with a proper astringent. 
The tincture of iron will be found serviceable. Tannin in so- 
lution with glycerin is also good. I have found in the fluid 
hydrastis, one drachm to the ounce of water, an admirable 
injection in these cases. All the instructions that have been 
given for the treatment of constipation should be enjoined 
here, for the reason that constipation has been the prime 
cause of the trouble. Numerous remedies have been sug- 
gested for internal purposes, but I can think of none better 




A rectal irrigator. 



IMPACTED F^CES. 511 

than a daily administration of the minimum dose of strych- 
nine, combined with aloin, belladonna, or cascara sagrada. 
The pharmacists put up an admirable pill of this kind. 
Faradization is admirable in some cases. Of course the 
sedentary habit should be overcome, and it should never be 
forgotten that walking is the best of all exercise. It was 
said by some old writer that he believed that walking would 
overcome all the ills that flesh was heir to. I can not quite 
agree to this opinion, but I am sure that this mode of exer- 
cise will be found more serviceable in the majority of cases 
than any other known to the human race. Therefore advise 
your patient to walk or to ride, get into the open air, and avoid 
close confinement and sedentary habits of every kind. His 
diet, too, should be looked after. People sometimes think 
that they should be allowed to eat everything, and as much 
as the appetite calls for. There never was a greater mistake 
made. Certain articles of diet should be interdicted, such as 
the sweets, which include pastry, candies, etc. Others should 
be commanded, such as nutritious food, but overeating 
should be positively forbidden. 

I can not finish this chapter without saying that the hy- 
giene of the lower bowel has never received the proper atten- 
tion. It must be admitted that the subject of constipation is a 
very important one, and that when such a habit is established, 
it is a most difficult thing to manage. Patients come to us 
complaining of many symptoms which are really trivial in 
their nature, and yet they are treated by much medication ; 
but this subject, which is of rare importance, is neglected. 
Children are not responsible for the non-observance of the 
rules of health, but it must be remembered that many of their 
affections can be traced to the want of the proper observance 
of the regular daily habit of evacuating the bowel. Such a 
condition not only does harm in a local way, but is accounta- 
ble often for a general diseased condition. Men seem to be 
on a rush in their purpose to make money, and neglect their 
health, when attention to a few details might prevent them 
from an attack of illness, or keep them in a healthy condi- 



512 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

tion. Women, through their false modesty, will sometimes 
defer or prevent the action of the bowels, and in consequence 
suffer for years. I remember once to have had a lady patient 
who boarded at one of the hotels of the city, who came to me 
to be treated for obstinate constipation, and among the ques- 
tions that I asked her was, whether her room was convenient 
to the water-closet. She replied that it was not, and that she 
was compelled to go through a couple of long halls before 
reaching it. I then asked her if it was not a fact that if she 
saw a gentleman in the hall, or met with one on the way, she 
would not turn back. Her answer was: "Of coarse I do." 
After giving her some general directions, I suggested that she 
have her room changed to the floor on which the water-closet 
was located, and positively instructed her to allow nothing to 
interfere with her going regularly and at a certain time to 
have her bowels evacuated. 

Persons will allow business or pleasure, or even trivial 
things, to interfere with this very important matter. A few 
days ago a lady said to me — who was the wife of one of my 
patients at the time — that her bowels had not moved for a 
week, for the reason that she had been so constantly at the 
bedside of her husband. Of course this was no excuse, but 
it shows the necessity of the physician being on constant 
guard to prevent any such thing occurring. 

The regular performance of this act is one of the prime 
conditions to good health, and a departure from it results in 
distress. Women will ride in their cushioned carriages and 
never think of the importance of taking physical exercise, un- 
til they are stricken with some malady as the result of their 
imprudence. We often hear persons say that they are natu- 
rally costive. This is a misconception, for Nature has nothing 
to do with such a condition. Doctors sometimes lose their 
health by owning and using a carriage constantly in their 
practice. It never was intended that people should live at 
such ease. The daily toiler who walks to and fro from his 
work and wields a sledge-hammer during the day may not 
have as many of the luxuries of life as the rich, but he has 



IMPACTED F^CES. 513 

good health, which is a boon that money can not buy. 
Families who place themselves under our medical treatment 
deserve also to be told of those things which will prevent 
sickness, and it should never escape our minds to inform par- 
ents how to instruct children in the simple rules of health. 



33 



CHAPTER XXIII. 
VILLOUS TUMOR OF THE RECTUM. 

I believe a villous tumor to be the rarest of all rectal 
affections. In my experience of fifteen years devoted to rec- 
tal practice I have seen but one case. Mr. Quain in his 
work gives the details of only two cases that had fallen un- 
der his observation. Allingham, Sr., with his large experi- 
ence, only reports eleven cases, three of these having been 
under the care of Mr. Gowlland, one in the practice of 
Mr. Cooper, and three under Mr. Groodsall's care. Mr. Symes 
reports two cases, and Cripps, Goselin, Van Buren, Bryant, 
and Cook one case each. 

The tumor is likely to be mistaken for a polypus, because 
it is attached to the bowel by a stem. The stem itself, how- 
ever, is of some significance, as in polypi it is round, and in 
the villous tumor is broad. Like polypi, the pedicle may be 
long or short. Some instances are reported where no stem 
could be detected, and the tumor was attached by a broad, 
thick base. Allingham says: "In cases where the growth 
arises from the perineal surface, as a practical point worth 
remembering, I should say it is by no means impossible that 
a pouch of peritonaeum may be dragged down into the pedi- 
cle, and in such a case, if the ligatures were applied close to 
the bowel, the peritoneum might be tied up with it." I can 
scarcely understand how the peritonaeum could be included 
in the stem of such a growth. 

I will consider the symptoms of a villous tumor by recit- 
ing the case which occurred in my own practice : 

Case. — Mr. McC, aged about fifty-five, of small stature 
but stout build, came into my office saying that hedesired to 



VILLOUS TUMOR OF THE RECTUM. 51 5 

consult me in regard to his piles. He sat down and gave me 
a history of their protruding at stool, and of his pushing 
them back after each evacuation of the bowel. He said this 
had been the case for about two years ; that they had always 
bled a little when prolapsed, but that for the last two months 
he had lost so much blood that it was showing upon him, and 
that npon one occasion he had fainted during the act of defe- 
cation, from the excessive loss of blood. When asked as 
to the quantity, he replied that at the last action of the 
bowel he had lost fully a pint. I appointed the next day to 
go to his residence and operate npon him. Taking my assist- 
ant along to give the anesthetic, I fonnd npon an examina- 
tion that the tumor was protruding from his rectum, and that 
it could be easily ligated without the use of the anaesthetic. 
I immediately detected, however, that the tumor was not 
hemorrhoidal. It was a large spongy mass, bleeding freely 
at the time, very soft to the feel, and attached to the bowel 
by a stem about one inch long. While my assistant held 
the bnttocks apart, I threw a silk ligature as close to the at- 
tachment of the pedicle as possible, tied it firmly, and cut the 
tumor off. It proved to be a villous growth. No further 
hemorrhage took place, and the man regained his usual physi- 
cal condition. 

Dr. George J. Cook reported a case of villous tumor in 
the Weekly Medical Review, a short time ago, that is more 
than ordinarily interesting, and I therefore take pleasure in 
inserting it here : 

"On December 28, 1887, Dr. Cline, of this city, called me 
to see Mrs. S., aged forty, formerly robust and healthy, the 
mother of several children and still menstruating. About 
five years previous she began to have at times some pain 
in the rectum and sacral region, dull and aching in charac- 
ter, and noticed occasionally a free discharge of mucus. 
These symptoms of rectal disease gradually increased until 
the pain became almost constant during the day-time, when 
she was attending to her household duties, and the discharge 
of mucus of daily occurrence. During the previous six 







516 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

months she had been losing flesh and strength gradually, 
and was now confined to her bed most of the time on ac- 
count of general weakness and the distress in the rectum 
when in the upright position. 

"For two months past a tumor would present at the 
anus while straining at stool, but never entirely prolapsed, 
and occasionally some blood was lost. There was one natural 

passage from the bowels daily, 
but several times a day a large 
quantity of thin mucus would 
pass, sometimes a half-pint or 
more at once. Her appetite was 
poor, could take but little food, 
and her skin was pale and waxy 
in appearance. Her history and 
appearance suggested some form 
of malignant disease. On digital 

Villous tumor. (Cook.) . 

examination, I recognized a tu- 
mor resting in the rectal pouch, well above the internal sphinc- 
ter muscle. It was different from anything I had ever before 
felt in the rectum ; so slippery that it was with difficulty held 
beneath the finger for examination, of a spongy consistence, 
with no induration, and firmly attached to the posterior rectal 
wall. When the patient was placed under an anaesthetic and 
the sphincters dilated, the tumor was easily drawn outside. 
It was the size of a large hen's egg, of a bright arterial color, 
had no pedicle, but grew from the gut wall by a broad base. 
A fold of mucous membrane was dragged down to allow it to 
come outside the anus. There was some thickening of the 
fibrous tissue at the base, and from this sprang long, villous 
processes which composed the bulk of the tumor. Each one 
of these increased in size from the base toward the free ex- 
tremity, giving its ends a clubbed appearance. The outline 
of the tumor was very distinct. There was no surrounding 
zone of congested or inflamed membrane, but the healthy tis- 
sue came up to the outer row of villi. The contrast in color 
was marked. The surrounding membrane was pale, owing 



VILLOUS TUMOR OF THE RECTUM. 



517 



to the great debility of tlie patient, and the tumor was of a 
bright arterial hue. It was removed by passing a double 
ligature through the folds of mucous membrane above it, 
tying and then cutting off with a knife. The ligature came 
off after a few days, and the patient made a rapid recovery, 
soon becoming strong and more fleshy than ever before in 
her life." 

As these cases are so rare and so easily diagnosticated if 
found, it is scarcely necessary to say anything further con- 
cerning them, except that when detected they should be 
removed, either after the manner suggested by Cook or as 
practiced in my own case. 









CHAPTER XXIV. 

MALF0KMATI0NS OF THE RECTUM AND ANUS. 

It is estimated that in every 4,538 births there is one of 
malformation of either the rectum or anus. Anger states that 
he met live instances of imperforate anus in two thousand 
midwifery cases. Duncalfe reports five cases in two thousand 
births. Teinturier, in a paper read on this subject, mentions 
that he had collected statistics of seventy-three thousand con- 
finements, and out of these there were only seven cases of im- 
perforate anus. So it can be clearly seen that these cases are 
exceedingly rare, and their observation nearly accidental. I 
shall not consider it necessary to deal with the pathology of 
these malformations, but desire to state that Ball has dis- 
cussed this subject very ably and fully in his admirable work 
on The Rectum and Anus. 

The following is Bodenhamer's classification, which, in a 
certain way, is the best that I have ever seen on the subject : 
" 1. This species consists of a preternatural narrowing or 
stenosis of the anus at its margin, and occasionally extend- 
ing a short distance above this point. 2. In this species there 
is a complete occlusion of the anal aperture by a simple mem- 
brane, or by the common integument, or a substance analo- 
gous to it, more or less thick and hard. 3. In this species 
there is no anus v/hatever ; the rectum, being partially deficient, 
terminates in a cul-de-sac at a greater or less distance above 
its natural outlet. 4. The anus in this species is normal, but 
the rectum at variable distances above it is either deficient, 
obliterated, or completely obstructed by a membranous sep- 
tum. 5. In this species the rectum terminates externally by 
an abnormal anus, located in some unnatural situation, as at 






MALFORMATIONS OF THE RECTUM AND ANUS. 519 

some point in the sacral region or at different points in the 
perineum ; or it may be prolonged in the form of a fistulous 
sinus, and terminate by an abnormal anus at the glans penis 
or the labia pudendi. The normal anus being generally ab- 
sent, its functions are more or less imperfectly performed by 
the abnormal one. 6. The rectum in this species opens pre- 
ternaturally into the bladder, urethra, or vagina, or into a 
cloaca in the perinseum with the urethra and vagina. In 
these instances the normal anus does not generally exist. 7. 
In this species the rectum is normal, with the exception that 
either the vagina or the uterus opens preternaturally into it. 
8. In this species the rectum is entirely wanting. 9. The rec- 
tum and colon in this species are both absent, and some other 
portion of the intestinal canal terminates externally in the 
preternatural anus in some extraordinary part of the body, 
such as the umbilicus, the left iliac fossa, the lower part of 
the abdomen, just above the symphysis pubis, below the 
scapula, and at the side of the face, as it has been known 
to have occupied each of these situations. No normal anus 
ever exists." 

The author just quoted from has shown a wonderful 
amount of research in collecting statistics on the subject 
and in reporting his own cases ; therefore it is well to note 
the nine classifications which he gives in order to demonstrate 
what curious facts exist in contemplating these malforma- 
tions. A more practical division would be the following : 

The Congenital Malformations of the Anus— I. Narrow- 
ing or partial occlusion. 2. Total occlusion. 3. Complete 
absence. 

Malformations of the Rectum.— 1. Partial occlusion. 2. 
Complete obliteration. 3. Unnatural termination. 4. Ab- 
sence of the rectum. 5. Communication with the vagina. 

I say for practical reasons, and, looking to an operation for 
relief, this, to my mind, is a better classification. Recognizing 
the fact that more serious conditions do exist, as has been 
proven by Bodenhamer's nine divisions, we must also admit, 
first, that a number of them are exceedingly uncommon ; and, 



520 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

second, if found, but very little, if anything, can be done for 
them. 

Symptoms. — The symptoms of a congenital obstruction of 
the bowel are usually discovered by the mother, for at the 
time of delivery it is scarcely every noticed by the attending 
physician. She may, within a day or two, call attention to 
the appearance of the child in this particular, or if four or 
five days have elapsed the child will begin to vomit, and the 
abdomen becomes distended. The most difficult part of the 
matter is to make out a clear diagnosis of the manner or form 
of malformation that exists. Yery grave mistakes have been 
made, and surgery done which was not warrantable. If it be 
a case of occlusion of the anus by a thin membrane, it can, as 
a rule, be easily diagnosticated. By a close scrutiny it will 
be observed that there is a slight ponting at the natural site 
of the anus and a bluish appearance noticed. By the touch 
it will be indicated that just beneath this thin septum is the 
natural contents of the bowel. 

But there may be a condition of occlusion of the anns, 
complicated also with an occlusion of or an entire absence 
of the rectum ; and yet this can not be definitely told until 
an incision is made. Granting, however, that the anus exists 
in its natural site, the symptoms of vomiting and distention 
of the abdomen may occur, and an occular inspection would 
not reveal the cause of the trouble. Therefore an introduc- 
tion of an instrument or the finger into the rectum may reveal 
the condition, which may be an obstruction in the rectum, 
and yet an obstruction may exist beyond the reach of the 
finger. In such a case, if the symptoms are positive, it will 
be necessary to nse a longer sonnd, or to inject water, and 
observe whether it passes beyond the part or not. 

Prognosis.— Physicians are often able to give much comfort 
to the friends of the afflicted by assuring them that a patient 
can be fully restored to health, or, if not, can be put in a con- 
dition in which they can enjoy life. We must, however, ad- 
mit that the prognosis in these cases— malformation of the 
rectum— is exceedingly grave. Not only is it the case that if 



MALFORMATIONS OP THE RECTUM AND ANUS. 521 

an operation is done in the majority of cases it proves fatal, 
but that, if it is successful so far as the operation is concerned, 
the effect is to condemn the infant to a life of suffering and 
disgust. In a paper read before the Mnth International 
Medical Congress, held at Washington, the caption of which 
was, When is Colotomy Justifiable % I stated, as one of 
my conclusions, that I did not believe colotomy should be 
done where there was a congenital absence of the rectum, or 
where the malformation consisted in preternatural termina- 
tions of the rectum. I argued that in this matter, in which 
the infant could have no option, I believed that it was best 
not to inflict upon it a life of misery and disgust, taking in 
consideration also the fact that opening the colon, either in 
the groin or the loin, usually resulted in death. Cripps says, 
in his excellent work : " A doubt seems to have risen in the 
minds of many as to whether any attempt should be made to 
deal surgically with such a condition, as the only effect of 
successful surgical interference is to condemn the infant to a 
life of suffering from a contracted anus or an artificial open- 
ing in the groin." He adds : "It would appear to be scarcely 
in the province of a surgeon to constitute himself the arbitra- 
tor between life and death." 

In answer to this proposition I would say that after a 
person had attained to manhood, and were to have the 
question asked whether, if he had had the power to decide, 
would he have had the operation performed, I can not 
imagine that a single one would answer in the affirmative. 
It has been seriously discussed by intelligent people whether 
life is worth the living at best. Surely under the con- 
ditions that would exist after either one or the other of the 
operations suggested for such malformations, life would be 
anything but worth living. It is fortunate, however, that 
the cases are few where a surgeon is called upon to give an 
opinion. But, as far as I myself am concerned, I must still 
hold to my original impression that it is not best to do an 
operation under such circumstances. 

Treatment. — In the cases of congenital malformation of the 



522 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

anus, especially those detailed by me in this chapter, it is 
fully warrantable to do enough surgery either to clear up 
the diagnosis or to see if relief can be afforded. If a partial 
occlusion of the anus exist, it can be enlarged. If a total oc- 
clusion presents itself, an incision should be made through 
the thin or thick membrane. In my practice I have seen two 
cases of congenital malformation of the rectum, and one case 
of an occlusion of the anus by a thin membrane. My first 
case was a male child with no trace of the anus at all. I 
made an incision in the natural site to the depth of two 
inches and no rectum could be found. I desisted from any 
further cutting, and the parents objected to a colotomy, for 
which decision I was very thankful. 

My second case was a female child in the wards of the 
City Hospital, and was very much like the first. I could find 
no unnatural opening anywhere. An incision was made but 
no bowel was found. The depth of the incision was not more 
than an inch and a half. It was decided by the hospital staff 
to do a colotomy the next day, but fortunately, for the child 
at least, it died within twenty-four hours. 

Both of these cases were, in a certain way, well adapted 
for a colotomy, because there was no unnatural opening any- 
where, and yet I could not bring myself to the conclusion 
that such operation was to be preferred to cutting down at 
the natural site, or that a colotomy was justifiable at all. 

The following abstract from Cripps's table of operations 
for these malformations, shows this mortality : 

1. Colon opened in the groin 16, died 11 

2. Colon opened in the loin 3 " 2 

3. Puncture 17 " 14 

4. Coccyx resected 8 " 5 

5. Perineal incision or dissection 39 " 14 

6. Communication between the rectum and vagina. . 14 " 1 

7. Miscellaneous 3 " 3 

100 50 

Cripps says: " Of course it is not right to compare the 
death-rate following upon Littre's and Amussat's operation 
with that resulting from operations in situ" 



MALFORMATIONS OF THE RECTUM AND ANUS. 523 

This point is well taken by the author when we remember 
that in the majority of cases in which the colon was opened 
the operation was only undertaken as a last resource after 
failing to find the bowel in the perineum. I would ask if it 
would not have been better, knowing what a fearful mortality 
results from operations in situ, to have desisted from per- 
forming a second operation, which was in itself more danger- 
ous than the first, and made doubly dangerous by having 
done two operations instead of one. I would also call atten- 
tion to the fact that at first glance Cripps's table would appear 
to be highly satisfactory, when we consider that one hundred 
operations were done for malformation with only fifty 
deaths, showing a percentage mortality of fifty. But if an 
examination of his table is made, it will be noticed that four- 
teen operations were done, establishing a communication be- 
tween the rectum and the vagina, with one death. This op- 
eration can scarcely be called an operation, in so far as the 
average mortality is to be made up for the surgery done for 
malformations proper. We would naturally suppose that 
such an operation as is called for in this condition of affairs 
would not result in death at all. But when we come to con- 
sider the two operations which could be called legitimate, or 
at least those usually done for malformations— viz., colotomy 
and deep cuts or dissections at the natural site— we witness a 
very heavy mortality. Indeed, I would consider colotomy to 
be the proper operation in the majority of cases of malforma- 
tions of the rectum, if I believed in this operation for the re- 
lief of this condition at all, first, because it gives absolute 
relief to the patient if the operation is successful ; and, sec- 
ond, there is really less surgery done. But another reason 
which leads me to this conclusion is, that it will be observed 
in the cases where Cripps practiced puncture seventeen times 
he had fourteen deaths. Now, this same mortality has fol- 
lowed this method of procedure in the reported cases of many 
surgeons, and although it would appear that we should take 
warning from such a mortality rate, it is a well-known fact 
that this is the common operation for such conditions. 



524 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 

I do not think it can be gainsaid that, first of all, a 
careful dissection in situ should be made in these cases of 
malformation for the purpose of finding the bowel, and yet I 
can not agree with the authors who say that if the bowel is not 
found, the operator should proceed at once to open the colon. 
To the contrary, recognizing how difficult it is to diagnose 
these cases properly, as to what the real unnatural condition, 
etc., is, and also that by making a dissection and the object 
fails, a double complication has been established if we do a 
colotomy, I should hesitate before opening the colon. In- 
stead of proceeding at once to do a colotomy after a failure 
at the natural site, I think time should be taken to explain to 
the parents not only the danger of the second operation, but 
the disgusting effects which will result. As far as safety is 
concerned in doing an operation in one or the other locality, 
I believe that colotomy would be accompanied with the best 
results, and, if the consent of the parents has been obtained, 
it would be better to do this operation first, thereby saving a 
double operation and incurring additional risk. If it has 
been determined, therefore, to open the colon, the question 
would be as to which was the best site — in the loin or the 
groin. In dealing with colotomy in another chapter, I have 
taken occasion to say that I believe Amussat's operation is 
to be recommended in cases of cancer of the rectum or sig- 
moid flexure above Littre's ; but in these cases of malforma- 
tion in the infant I certainly believe that the groin should 
be selected for the operation. The manner of doing this op- 
eration has already been described. It has been questioned 
by surgeons whether the right side or the left should be se- 
lected, because of the frequency with which the sigmoid flex- 
ure is turned toward the right. The cases are very frequent 
where this part of the colon is found on the right side in the 
infant, and yet I believe with Cripps that the operation is 
more likely to open the sigmoid flexure on the left than on 
the right side. I think that the scheme which consists in 
passing a bougie or catheter by the groin opening into the 
cul-de-sac of the bowel below, and pressing down on the pel- 






MALFORMATIONS OF THE RECTUM AND ANUS. 525 

vis, and to be cut down npon from the perinseum, should be 
deprecated. I scarcely think that in any case such a proced- 
ure is justifiable. It is not only dangerous, but it is unneces- 
sary. If a colotomy has been done, we should be content 
with the operation. 

It can be said of these operations, whether by dissec- 
tions in situ, punctures, or either one of the colotomies, that 
they are generally unprofitable and dangerous. I have not 
seen fit to occupy much time in discussing the malformations, 
and to those who desire a full and complete dissertation on 
the subject I would respectfully refer them to the works of 
Curling, Bodenhamer, Cripps, and Ball. 



INDEX 



Abscesses as a cause of fistula in ano. 
180. 

following stricture of rectum, 185. 
Abscesses of rectum, Allingham's meth- 
od of opening, 187. 

author's method of opening, 187. 
Agnew on injections of carbolic acid in 
internal haemorrhoids, 142. 

on the fistulatome, 216. 

on use Of caustics in fistula in ano, 210. 
Alcohol in chronic constipation, 67. 
Allingham, on author's report on injec- 
tions of carbolic acid in internal 
haemorrhoids, 138. 

on clamp and cautery in internal haem- 
orrhoids, 146. 

on effects of irritable ulcer of rectum, 
310. 

on excision of internal haemorrhoids, 
148. 

on incising ulcers of rectum, 287. 

on inguinal colotomy, 397. 

on neuralgia of rectum, 260. 

on plugging rectum after operations 
on interna] haemorrhoids, 175. 

on treatment of fistula in ano by liga- 
ture, 231. 

on uterine displacements in haemor- 
rhoids, 119. 
Allingham's method of doing inguinal 
colotomy, 397. 

method of opening abscesses of rec- 
tum, 187. 

ointment for internal haemorrhoids, 
134. 

Aloes in chronic constipation, 71. 
Amussat's operation, 390. 
Anaesthesia in examination of rectum, 26. 
local, 91. 

Vance on, 91. 
Wood on, 92. 



Anaesthetic, chloroform as an, 92. 
ether as an, 92. 
rhigolene as a local, 91. 
whisky as an, 90. 
Anatomy and physiology of defecation, 

44, 53. 
Anatomy of rectum, 33. 
division, 34. 
effaceable folds, 37. 
ineffaceable folds, 37. 
importance of, 33. 
in relation to reflexes, 289. 
surgical importance of, 34. 
Andrews on author's operation for fist- 
ula in ano, 216. 
on injections of carbolic acid in inter- 
nal haemorrhoids, 136. 
Antisepsis, asepsis and, 84. 
Antiseptics in rectal surgery, 80. 

list of, 81. 
Anus, boric acid in lesions of, 73. 
external sphincter muscle of, 39. 
external sphincter muscle of, result of 

injury to, 39. 
fissure of, 4, 267. 

cases, 270, 271, 273. 

causes, 269. 

divulsion in, 282. 

examination and diagnosis, 271. 

location, 270. 

operation for. 281. 

symptoms, 273. 

treatment, 279. 
internal sphincter muscle of, 40. 
itching of, 13. 
malformations of, 518. 

congenital, 519. 

prognosis, 520. 

symptoms, 520. 

treatment, 521. 
prolapse of, 467. 



528 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



Anus, prolapse of, diagnosis, 472. 
ergotin in, 489. 
forms of, 469. 
treatment, 478. 

author's method, 488. 
operation, 481. 
pruritus of, 493. 
a symptom, 493. 
aetiology, 493. 
symptoms, 497. 
treatment. 498. 

applications for, 501. 
hot water, 499. 
hypnotics, 499. 
iodine, 500, 
operation, 504. 
Appendicitis, obstruction and, 46. 
Asepsis and antisepsis, 84. 
Astringents in treatment of external 
haemorrhoids, 106. 

Ball on dilatation of rectum, 284. 
Bangs on dilatation of stricture, 354. 
Bauer on dilatation of rectum, 351. 
Billroth on iodoform as a dressing, 82. 
Blood, effect of faeces on, 48. 
Bodenhamer on malformations of rectum 

and anus, 518. 
Boric acid in chronic constipation, 72. 

in lesions of anus, 73. 
Bougie in internal haemorrhoids, 134. 

Wales's rectal, 20, 22. 

Chadwick on introduction of rectal, 52. 
Bowel, case of obstruction of, 24. 

hygiene of lower, 511. 

desire for evacuation of, 53. 
Braun on volvulus of sigmoid flexure, 

460. 
Briddon on prolapsus ani, 483. 
Brodie on diet in internal haemorrhoids, 

131. 
Bryant on colotomy, 383, 391. 

on lumbar colotomy, 391. 
Bryson on stricture of rectum, 353. 
Bull on extirpation of sigmoid flexure, 
456. 

on injections of carbolic acid in inter- 
nal haemorrhoids, 143. 

Cancer, irritable ulcer of rectum mis- 
taken for, 311. 
Cancer of rectum, 366. 
advantages of extirpation, 420. 



Cancer of rectum, cases, 28, 30, 31, 378, 379. 
causes, 380. 
classification, 374. 
diagnosis, 369. 
differential, 372. 
method, 371. 
distinction, 375. 
duration of life in, 385. 
extirpation and palliative treatment 

of, 407. 
heredity of, 367. 
local origin, 376. 
mortality in, 411. 
plan of operation in, 414. 
results of operations in, 413. 
symptoms, 378. 
treatment, 383. 
colotomy, 383. 
advisability of, 386. 
method, 390. 
inguinal, 394. 

method of doing, 394. 
condition of patient after opera- 
tion, 402. 
lumbar, manner of doing, 403. 
risk of life, 390. 
palliative, 421. 
cases, 424. 
varieties, 376. 
Cancer of sigmoid flexure, 451. 
diagnosis, 453. 
extirpation, 455. 

Bull on, 456. 
laparotomy for, 25. 
prognosis, 454. 
symptoms, 451. 
cachexia, 452. 
character of stools, 452. 
irregularity of bowel, 452. 
pain in, 452, 
Carbolic-acid injections in internal haem- 
orrhoids, 136. 
Carlsbad water in internal haemorrhoids, 

130. 
Cascara sagrada in constipation, 64. 
Catarrh, gastro-intestinal, 71. 
of intestines, 444. 
of rectum, 448. 
Catgut in colotomy, 83. 
Caustics in treatment of fistula in ano, 

209. 
Chadwick on introduction of rectal bou- 
gies, 52. 



INDEX. 



529 



Chadwick on third sphincter, 51, 54, 55. 
Chloroform as an anaesthetic, 92. 
Clover's crutch, 16. 
Colitis, 445. 

Colon, absorbing powers of, 74. 
diuretic effect of water injected into, 

78. 
effect upon kidney by water injected 
into, 77. 
Colotomy, 364, 383. 
catgut in, 83. 
justifiability of, 405. 
inguinal, Allingham's method of do- 
ing, 397. 

author's method, 400. 
condition of patient after operation, 

402. 
Cripps's method of doing, 394. 
different methods of doing, 397. 
Kelsey's method of doing, 399. 
method of doing, 394. 
Reeves's method of doing, 397. 
lumbar, manner of doing, 403. 
Congestion of sigmoid flexure, 438. 
Constipation, 44. 
a relative term, 9. 
a unique case of, 58. 
as a cause of fistula in ano, 182. 
diet in, 62. 
effects of, 5, 46, 48. 
effects of, on muscles, 56. 
effects of soap in, 63. 
examining rectum in, 61. 
exercise in, 62. 
glycerin in, 65. 
haemorrhoids caused by, 48. 
importance of, 44. 
produced by injections of water, 63. 
purgatives in, 47, 57. 
role of muscular fibers of rectum in, 36. 
treatment of, 60. 
water in, 62. 
Constipation, chronic, 63. 
alcohol in, 67. 
aloes in, 71. 

bichloride of mercury in, 71. 
boric acid in, 72. 
cascara sagrada in, 64. 
Cook on effects of water injections in, 

74. 
Dover's powders in, 65. 
Flatau on treatment of, 72. 
flushing rectum in, 69. 
34 



Constipation, hydrastis canadensis in, 

69. 
injection for, 69. 

involvement of large intestine in, 69. 
iron in, 71. 
massage in, 66. 
mineral waters in, 71. 
nicotine in, 71. 
pill-habit in, 66. 
prescription for, 67. 
purgatives in, 70. 

solution of albuminate of iron in, 64. 
strychnine in, 71. 
tonics in, 66. 
Trommer's malt in, 64. 
water in, 71. 
Consumptives, frequency of fistula in 

ano in, 204. 
Cook on effects of water injections in 

chronic constipation, 74. 
on villous tumor of rectum, 515. 
Copeland on incision through mucous 

membrane of anus, 283. 
Cripps on abscesses as a cause of fistula 

in ano, 183. 
on bougie in internal haemorrhoids, 

134. 
on method of doing inguinal colotomy, 

394. 
on preparation of patient for operation 

on internal haemorrhoids, 161. 

Defecation, anatomy and physiology of, 
44, 53. 

O'Beirne's theory concerning, 44. 

eversion of mucous membrane during, 
45. 
Diarrhoea as a cause of inflammation of 

sigmoid flexure, 446. 
Diet in constipation, 62. 

in internal haemorrhoids, 130. 
Dilatation in stricture of rectum, 350. 
Disinfection of instruments, 87. 

of operative region, 87. 

of persons, 86. 

of sponges, 87. 

of wound, 88. 
Dittel on treatment of fistula in ano by 

ligature, 231. 
Divulsion in fissure of anus, 282. 

in irritable ulcer of rectum, 282. 

of rectum, Sims's position for, 286. 
Dolbeau on dilatation of rectum, 284. 



530 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



Dover's powders in chronic constipation, 
65. 

Dumarquay on submucous division of 
sphincter muscle, 283. 

Dupuytren on dividing sphincter mus- 
cle, 282. 

Dysentery as a cause of ulceration of 
rectum, 318, 331. 

Electrolysis in stricture of rectum, 361. 
Enema, importance of,, before examina- 
tion, 13. 
Ergotin in prolapse of anus, 489. 
Erich sen on fistula in ano as a deriva- 
tive in consumption, 207. 
Ether as an anaesthetic, 92. 
Evacuation of bowels, desire for, 53. 

in diseases of sigmoid flexure, 447. 
Examination of rectum, 12. 

accidents from introduction of hand, 
24. 

anaesthesia in, 26. 

finger in, 17. 

hand in, 23. 

illumination in, 15. 

importance of an enema before, 13. 

importance of probe in, 21. 

in relation to life insurance, 26. 

Nedofik sofa for, 12, 14. 

position of patient in, 16. 

speculum in, 19. 
Excision of rectum, 415. 
Exercise in constipation, 62. 
Extirpation of cancer of rectum, ad- 
vantages of, 420. 

Fasces, effect of hardened, on sigmoid 
flexure, 428. 
effect of, on blood, 48. 
impacted, 506. 
case, 507. 
effect of, 508. 
symptoms, 508. 
treatment, 509. 
diet, 511. 
divulsion, 509. 
faradization, 511. 
injections, 510. 
Fissures of anus, 5, 267. 
cases, 270, 271, 273. 
causes, 269. 
divulsion in, 282. 
examination and diagnosis, 271. 



Fissures of anus, location, 270. 
operation for, 281. 
symptoms, 273. 
treatment, 279. 
Fissure of rectum, character of pain, 276. 
Fistula in ano, 179. 
after-treatment of, 238. 
author's operation for, 214. 
cases of, 189-193. 
causes of, 179. 
abscesses, 180. 
seat of, 184. 
varieties of, 183. 
constipation, 182. 
traumatism, 180. 
effect of organic lesions on cure of, 207. 
frequency of, 179. 

in consumptives, a derivative, 207. 
frequency of, 204. 
healing of wound in, 206. 
question of operation in, 204. 
relation of, to phthisis, 202. 
author's operation for, 211. 
operation for, by fistulatome, 213. 
by knife, 219. 
case, 228. 

examination of patient, 225. 
method of, 222. 
preparation of patient, 218, 221. 
treatment of, 209. 
caustics in, 209. 
by ligature, 230. 
advantages of, 233. 
value of, 231. 
varieties of, 188. 
blind external, 196. 
cases of, 198, 199. 
blind internal, 200. 
complete, 194. 

location of, 195. 
horseshoe, 201. 
treatment of, 237. 
Flatau on treatment of chronic constipa- 
tion, 72. 
Follicles of Lieberkuhn, 291. 
Foreign bodies as a cause of ulceration 
of rectum, 333. 
in sigmoid flexure, 459. 
Fothergill on pruritus ani, 496. 

Galen on prophylactic effect of internal 

haemorrhoids, 118. 
Gangrene in internal haemorrhoids, 122. 



INDEX. 



531 



Glycerin in chronic constipation, 65. 

Goodell on nervous or hysterical rec- 
tum, 243. 
on obscure diseases of rectum, 255. 

Gowlland's method of preventing hsem- 
orrhage after operations on inter- 
nal haemorrhoids, 174. 

Gross on cure of fistula in ano when 
organic lesions exist, 207. 

Haemorrhage following operation for in- 
ternal haemorrhoids, 170. 

causes of, 172. 

Gowlland's method of preventing, 174. 
Haemorrhage from rectum, 6, 10. 

in internal haemorrhoids, 112. 
cases of, 114. 
source of, 113. 

importance of, in diseases of rectum, 8. 
Haemorrhoids, 95. 

Allingham on uterine displacements 
in, 119. 

caused by constipation, 48. 

description of, 95. 

operations on, in uterine displace- 
ment, 120. 

seen with a speculum, 21. 
Haemorrhoids, external, 96. 

causes of, 97. 

danger in, 103. 

excision of, 100. 

inflammation in, 97. 

liability of recurrence of, 107. 

symptoms of, 97. 

treatment of, 99. 
astringents in, 106. 
carbolic-acid plan, 102. 
hamamelis in, 107. 
laxatives in, 105. 
ointments, etc., in, 102. 
palliative, 104. 
Haemorrhoids, internal, 109. 

capillary, 111. 

causes of, 109. 

complications of, 118. 

Cripps on bougie in, 134. 

diagnosis of, 126. 

examination in, 128. 

Galen on prophylactic effect of, 118. 

gangrene in, 122. 

haemorrhage in, 112. 
cases of, 114. 

Hamilton on columnar, 112. 



Haemorrhoids, internal, Hippocrates on 
evacuations from, 117. 
hypertrophy of prostate in, 121. 
inflammation, 113. 

water in, 133. 
large venous, 111. 
local applications in, 132. 
location of, 109. 
nasvoid, 112. 
nature of, 109. 
ointments in, 134. 
operations for, 135. 

clamp and cautery, 145. 

crushing, 145. 

dilatation of sphincter muscle, 

149. 
excision, 148. 

haemorrhage following, 170. 
causes of, 172. 

Gowlland's method of preventing. 
174. 
in inflamed condition, 122. 
injections of carbolic acid, 136. 

evil results from, 140, 141. 
ligature in, 158. 

after-treatment of patient, 166. 
complications, 168. 
dressings after, 164. 
inflammation after, 168. 
method of applying, 159. 162. 
preparation of patient, 160. 
methods, 136. 

preparation of patient, 135. 
tamponing rectum after, 175. 

author's method, 176. 
Whitehead's, 152. 
objections to, 153-157. 
pain in, 126. 
pathology of, 112. 
precautions against, 132. 
source of hemorrhage in, 113. 
supports for, 132, 133. 
symptoms of, 124. 
treatment of, 129. 
Brodie on diet in, 131. 
Carlsbad water in, 130. 
diet in, 130. 
palliative, 130. 
urethral stricture in, 121. 
Van Buren on injections in, 133. 
varieties of, 110. 
washing out rectum in, 128. 
white, 112. 



532 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



Haraamelis in treatment of external 
haemorrhoids, 107. 

Hamilton on columnar haemorrhoids, 112. 
on operation for fistula in ano by 
knife, 219. 

Hand, accidents from introduction of, in 
examination of rectum, 24. 
in examination of rectum, 23. 

Heister on cancer of rectum, 366. 

Heredity in cancer of rectum, 367. 

Heredity in rectal disease, 9. 

Hippocrates on evacuations from inter- 
nal haemorrhoids, 117. 

Hoffa on antiseptic method of wound 
treatment, 86. 

Houston's semilunar valves, 37, 41. 
location of, 37. 

Hurd on neuralgia, 260. 

Hydrastis canadensis in chronic consti- 
pation, 69. 

Hygiene of lower bowel, 511. 

Hysteria in relation to intestinal disease, 
447. 

Incision in stricture of rectum, 356. 
Indigestion, effect of, on intestinal tract, 

49. 
Inflammation after ligating internal 
haemorrhoids, 168. 
cause of stricture, 339. 
in externa] haemorrhoids, 97. 
in internal haemorrhoids, 113, 

water in, 133. 
of intestine, 429. 
of rectum, danger of stricture from, 

448. 
of sigmoid flexure, 438. 
cases, 430. 

diarrhoea as a cause of, 446. 
treatment, 449. 
result of traumatism, 340. 
Injection for chronic constipation, 69. 
Injections as aids to peristalsis, 70. 
Instruments, disinfection of, 87. 
Insurance, examination of rectum in re- 
lation to life, 26, 32. 
importance of examination of, in rela- 
tion to life insurance, 26, 32. 
Intestine, absorbing power of large, 
443. 
catarrh of. 444. 
inflammation of, 429, 
relation of sigmoid flexure to, 442. 



Intestine, involvement of large, in chronic 

constipation, 69. 
Iodoform as a dressing, 82. 

Billroth on, 82. 

in treatment of ulcer of rectum, 281. 

Marcy on, 82. 
Iron in chronic constipation, 71. 

solution of albuminate of, in chronic 
constipation, 64. 
Itching of anus, 13. 

Kelsey, classification of non-malignant 
stricture of rectum, 336. 
on dilatation of rectum, 350. 
on inguinal colotomy, 399. 
on injections of carbolic acid in inter- 
nal haemorrhoids, 142, 143. 
on third sphincter, 40. 
on ulcers of rectum, 270. 
on method of doing inguinal colotomv, 
399. 
Kidney, effect upon, by water injected 

into colon, 77. 
Kraske's operation for excision of rectum, 
416. 

Lange on excision of fistulous tracts, 
217. 
on prolapsus ani, 485. 

Laparotomy for cancer of sigmoid flex- 
ure, 25. 

Laxatives in treatment of external haem- 
orrhoids, 105. 

Leube on catarrh of rectum, 448. 

Life, modes of, as an influence in diseases 
of rectum, 4. 

Ligature in treatment of internal haemor- 
rhoids, 158. 
treatment of fistula in ano by, 230. 
advantages of, 233. 

Littre's operation, 390. 

Liver, diseases of, 

Maisonneuve on dilatation of rectum, 283. 
Malformations of anus, congenital, 519. 
Malformations of rectum and anus, 518. 

prognosis, 520. 

symptoms, 520. 

treatment, 521. 

mortality from operations for, 522. 
Malt, Trommer's, in chronic constipation, 
64. 



INDEX. 



533 



Marcy on iodoform as a dressing, 82. 
on secondary haemorrhage after White- 
head's operation, 156. 
Massage in chronic constipation, 66. 
Mercury, bichloride of, in chronic con- 
stipation, 71. 
Mineral waters in chronic constipation, 

71. 
Mucus, significance of, in discharges from 

rectum, 9. 
Muscle, a third sphincter, 40, 51, 55. 
external sphincter of anus, 39. 
effects of constipation on, 56. 
internal sphincter of anus, 40. 
levator ani, 41. 
recto-coccygeus, 42. 
results of injury of external sphincter 

of anus, 39. 
transversus perinei, 42. 

Neuralgia of rectum, 260. 

Allingham on, 260. 

cases, 261-262. 

causes, 263. 

treatment, 265. 
Nicotine in chronic constipation, 71. 

O'Beirne's theory concerning defecation, 

44. 
Obstruction and appendicitis, 46. 
Obstruction of bowel, case of, 24. 
Ointments in internal haemorrhoids, 134. 

in irritable ulcer of rectum, 280. 
Operations for rectal trouble in patients 

suffering from other diseases, 10. 
Opium in cancer of rectum, 388, 425. 
in preparation of patient for operation 

on fistula in ano, 218. 
Ouchterlony on stricture of rectum, 338. 

Pain in diseases of rectum, 8. 
Papillae of rectum, 37. 
Periproctitis, chronic contracting, 353. 
Peristalsis, aid of injections to, 70. 
Peroxide of hydrogen as a germicide, 

188. 
Phthisis, relation of fistula in ano to, 202. 
Physiology of defecation, 44, 53. 
Piles. See Hemorrhoids, 103. 
Pinus canadensis in diseases of sigmoid 

flexure, 432. 
Plexus myentericus of Auerbach, 70. 



Pockets in rectum, 37. 
Bodine on, 39. 
Dugan on, 39. 
Kelly on, 38. 
Probe, importance of, in examinations 

of rectum, 21. 
Procidentia. See Prolapse. 
Proctitis. See also Inflammation, 353. 

caused by hardened faeces, 447. 
Proctotomy, external, 357. 
for stricture of rectum, 30, 31. 
internal, 357. 
posterior, 359. 
Prolapse of anus, 467. 
diagnosis, 472. 
ergotin in, 489. 
forms of, 469. 
treatment, 478. 

author's method, 488. 
operation, 481. 
Prostate, hypertrophy of, in internal 
haemorrhoids, 121. 
mistaken for rectal tumor, 19. 
Pruritus of anus, 493. 
a symptom, 493. 
aetiology, 493. 
symptoms, 497. 
treatment, 498. 

applications for, 501. 
hot water, 499. 
hypnotics, 499. 
iodine, 500. 
operation, 504. 
Purgatives in chronic constipation, 
70. 
in constipation, 47, 57. 
Pus, significance of, in discharges from 
rectum, 9. 

Rectum, abscesses of, Allingham's method 

of opening, 187. 
author's method of opening, 187. 
following stricture of, 185. 
Rectum, accidents from introduction of 

hand in examination of, 24. 
anatomy of, 33. 

division, 34. 

effaceable folds, 37. 

ineffaceable folds, 37. 

in relation to reflexes, 289. 
surgical importance of, 34. 
blood-supply of, 42. 
Bodine on pockets in, 39. 



534 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



Rectum, cancer of, 366. 

advantages of extirpation, 420. 
cases, 28, 30, 378, 379, 408, 409, 418. 
causes, 380. 
classification, 374. 
diagnosis, 369. 

differential, 372. 

method, 371. 
distinction, 375. 
duration of life in, 385. 
heredity of, 367. 
local origin, 376. 
mortality in, 411. 
plan of operation in, 414. 
results of operations in, 413. 
symptoms, 378. 
treatment, 383. 

colotomy. advisability of, 386. 
method, 390. 

colotomy, inguinal, 394. 
condition of patient after opera- 
tion, 402. 
method of doing, 394. 
lumbar, manner of doing, 403. 
risk of life, 390. 

palliative, 421. 
cases, 424. 
extirpation and palliative treatment 

of, 407. 
varieties. 376. 
Rectum, catarrh of, 448. 
dilatability of female, 35. 
divulsion of, Sims's position for, 286. 
Dugan on pockets in, 39. 
effects of diseases of, on uterus, 11. 

of pressure on veins, 321. 

water injections upon secretion of, 78. 
examination of, 8, 12. 

anaesthesia in, 26. 

finger in. 17. 
effect of, 54. 

hand in, 23. 

illumination in, 15. 

in constipation, 61. 

in relation to life insurance, 26, 32. 
diseases of, necessity for thorough ex- 
amination, 278. 
position of patient in examination of, 

16. 
importance of probe in examinations 

of, 21. 
rules for examination and diagnosis 

of diseases of, 4. 



Rectum, speculum in examination of, 

19. 
excision of, 415. ' 

fissure of, character of pain, 276. 
flushing in chronic constipation, 69. 
haemorrhage from, 6, 10. 
importance of haemorrhage in diseases 

of, 8. 
irritable ulcer or fissure of, 267. 

difference between, 267. 
Kelly on pockets in, 38. 
malformations of, 519. 

prognosis, 520. 

symptoms, 520. , 

treatment, 521. 
modes of life as an influence in dis- 
eases of, 4. 
mucous membrane of, 36. 
muscular coat of, 36. 
nervous or hysterical, 242. 

cases, 246-249, 257. 

causes of, 250. 

Goodell on, 243. 

symptoms, 244. 

ulcers in, 251. 
neuralgia of, 260. 

Allingham on, 260. 

cases, 261, 262. 

causes, 263. 

treatment, 265. 
obscure diseases of, 252. 

aetiology, 256. 

foreign bodies as a cause, 253. 

Goodell on, 255. 
operations upon, in patients suffering 
from other diseases, 10. 

under whisky, 90. 
pain in diseases of, 8. 
papillae of, 37. 
plugging after operations on internal 

haemorrhoids, 175. 
pockets in, 37. 

proctotomy for stricture of, 30, 31. 
reflex power of, 10. 
relations of, 34. 

to vesical, uterine, urethral, and vagi- 
nal troubles, 34. 
risk in dilating upper portion, 36. 
role of muscular fibers of, in constipa- 
tion, 36. 
shape of, 34. 

significance of mucous discharges from, 
9. 



INDEX. 



535 



Rectum, significance of pus in discharges 
from, 9. 
stricture of, 9. 
analogy to stricture of urethra, 353. 
cases, 29. 30, 31. 
diagnosis, 344. 
non-malignant, 336. 
congenital, 336. 
dysenteric, 337. 
inflammatory, 339. 
Kelsey's classification, 336. 
spasmodic, 337. 
symptoms, 348. 
traumatic, 340. 
tubercular, 338. 
venereal, 340, 345. 

in demi-monde, 347. 
treatment. 350. 
colotomy, 364. 
dilatation, 350. 
electrolytic, 361. 
instruments, 361. 
method, 362. 
excision, 363. 
incision, 356. 
submucous coat of, 36. 
villous tumor of, 514. 

cases, 514. 
washing out in internal haemorrhoids, 

128. 
ulcers of, Kelsey on, 270. 
location, 268. 
operation for, 281. 
treatment, iodoform in, 281. 
varieties, 268. 

irritable, Allingham on effects of, 
310. 
Ball on effects of, 309. 
cases, 274, 275. 
character of pain, 276. 
Cripps on effects of, 310. 
divulsion in, 282. 
mistaken for cancer, 311. 
ointments in, 280. 
operation for, author's method, 284. 
treatment, 279. 
ulceration of, 318. 
cases, 318, 325. 
diathesis inducing, 322. 
dysentery as a cause, 318. 
in tubercular subjects, 324. 
case, 325. 
effects of operation, 326. 



Rectum, ulceration of varieties, 320. 
dysenteric, 331. 

treatment of, 332. 
foreign bodies, 333. 
scrofulous, 327. 
syphilitic, 328. 

treatment of, 329. 
tuberculous, 326. 
Reeves's method of doing inguinal colot- 
omy, 397. 
Reflex act, conditions necessary for, 
295. 
cases illustrating, 296-309. 
Reflexes, anatomy of rectum in relation 

to, 289. 
Rhigolene as a local anaesthetic, 91. 

Scrofula, 327. 

Sigmoid flexure, accumulation of faeces 

in, 46. 
cancer of, 451. 

diagnosis, 453. 

extirpation, 455. 

prognosis, 454. 

symptoms, 451. 
cachexia, 452. 
character of stools, 452. 
irregularity of bowels, 452. 
pain in, 452. 
case of stricture of, 29. 
congestion of, 438. 
diarrhoea as a cause of inflammation 

in, 446. 
diseases of, 427. 

cases, 430-437. 

evacuations in, 447. 

palliative measures in, 427. 

pathological conditions, 438. 

pinus canadensis in, 432. 
effect of hardened faeces on, 428. 
foreign bodies in, 459. 
inflammation of, 438. 

cases, 430. 

treatment, 449. 
laparotomy for cancer of, 25. 
relation to intestines, 442. 
simple ulceration of, 439. 
specific ulceration of, 440. 
syphilis in, 457. 

treatment, 458. 
volvulus of, 460. 
Sims's position, 16. 
for divulsion of rectum, 286. 



536 DISEASES OF THE RECTUM, ANUS, AND SIGMOID FLEXURE. 



Smith on treatment of fistula in ano, 

218. 
Soap, effects of, in constipation, 63. 
Sofa, Nedofik, for examinations, 12, 14. 
Sound, rectal, 23. 
Speculum, haemorrhoids seen with a, 21. 

in examination of rectum, 19. 
Sponges, disinfection of, 87. 
Stricture of rectum, 9. 
abscesses following, 185. 
analogy to stricture of urethra, 353. 
cases, 29, 30, 31. 
diagnosis, 344. 
proctotomy for, 30, 31. 
non-malignant, 336. 
congenital, 336. 
dysenteric, 337. 
inflammatory, 339. 
Kelsey's classification, 336. 
spasmodic, 337. 
symptoms, 348. 
traumatic, 340. 
tubercular, 338. 
venereal, 340, 345. 

in demi-monde, 347. 
treatment, 350. 
colotomy, 364. 
dilatation, 350. 
electrolytic, 361. 
instruments, 361. 
method, 362. 
excision, 363. 
Stricture of sigmoid flexure, case of, 29. 
of urethra in internal haemorrhoids, 
121. 
Strychnine in chronic constipation, 71. 
Surgery, rectal, antiseptics in, 80. 
list of, 81. 

preparation of patient for, 83. 
Syphilis in sigmoid flexure, 457. 
treatment, 458. 

Tetanus, result of operation on haemor- 
rhoids, 124. 

Traumatism as a cause of fistula in ano, 
180. 
inflammation, result of, 340. 

Trigone vesicale, width of, 36. 

Tubercular subjects, ulceration of rec- 
tum in, 324. 

Typhlitis, 65, 66, 445. 

Ulcer of rectum, 268. 



Ulcer of rectum, Allingham on incising, 
287. 
intolerant, 268. 
Kelsey on, 270. 
location, 268. 
operation for, 281. 
treatment, iodoform in, 281. 

ointments in, 280. 
tolerant, 268. 
varieties, 268. 
Ulcer of rectum, irritable, Allingham on 
effects of, 310. 
Ball on effects of, 309. 
cases, 274, 275, 311-316. 
character of pain, 276. 
Cripps on effects of, 310. 
divulsion in, 282. 
mistaken for cancer, 311. 
operation for, author's method, 

284. 
treatment, 279. 
Ulceration of rectum, 318. 
cases, 318, 325. 
diatheses inducing, 322. 
dysentery as a cause, 318. 
in tubercular subjects, 324. 
case, 325. 

effects of operation, 326. 
varieties, 320. 
dysenteric, 331. 

treatment, 332. 
foreign bodies, 333. 
scrofulous, 327. 
syphilitic, 328. 

treatment of, 329. 
tuberculous, 326. 
Ulceration, simple, of sigmoid flexure, 
439. 
specific, of sigmoid flexure, 440. 
Ulcers as a cause of nervous or hysterical 

rectum, 251. 
Uterine displacements, operations on 

haemorrhoids in, 120. 
Uterus, effects of diseases of rectum on, 
11. 
mistaken for rectal tumor, 19. 

Valves, Houston's semilunar, 37, 41. 

location of, 37. 
Vance on local anaesthetics, 91. 
Van Buren on injections in haemorrhoids, 
133. 

on prolapsus ani, 481. 



INDEX. 



537 






Van Hook on dilatation of rectum, 351. 

on incision in stricture, 359. 
Veins of rectum, effects of pressure upon, 

321. 
Villous tumor of rectum, 514. 

cases, 514. 
Volvulus of sigmoid flexure, 460. 

Wales's rectal bougie, 20, 22. 

Walker on dilatation of sphincter mus- 
cle in internal haemorrhoids, 151. 

Water, constipation produced by injec- 
tions of, 63. 
diuretic effect of, injected into colon, 78. 



Water in chronic constipation, 71. 

in constipation, 62. 
Webber on hysteria, 244. 
Weir on incision in stricture, 358. 
Whisky as an anaesthetic, 90. 

operations on the rectum under, 90. 
Whitehead's operation for internal haem- 
orrhoids, 152. 

objections against, 153-157. 
Wood on anaesthesia, 92. 
Wound, disinfection of, 88. 

treatment, Hoffa on antiseptic method 
of, 86. 
Wyeth on colotomy, 383. 



THE END. 



A PRACTICAL TREATISE ON THE 

SURGICAL DISEASES 

OF THE GENITO-TJRINARY 

ORGANS, 

INCLUDING SYPHILIS. 

DESIGNED AS A MANUAL FOR STUDENTS AND PRACTITIONERS. 

With Engravings. 

By E. L. KEYES, A. M., M. D., 

Professor of Genito-Urinary Surgery, Syphilology, and Dermatology 
in Bellevue Hospital Medical College. 

BEING A REVISION OF A TREATISE, BEARING THE SAME TITLE, BY 
VAN BUREN AND KEYES. 

SECOND EDITION, THOROUGHLY REVISED, AND SOMEWHAT ENLARGED. 



8vo. 688 -pages. Cloth, $5.00 ; sheep, $6.00. 



" The progress made in surgery during the last ten years, the changes of practice by the 
best surgeons with regard to several operative procedures, notably litholapaxy, suprapubic 
cystotomy, and operations upon the kidney itself, and other matters as well, rendered neces- 
sary a thorough revision of the work published some years ago as the joint production of Drs. 
Van Buren and Keyes. Much of the work has been rewritten entirely. There is a large 
amount of entirely new matter presented in this volume, to make room for which the reports 
of cases given in the former work are all omitted in this. The Avork in its present form 
stands fairly abreast of the latest advances in gen i to-urinary surgery. Dr. Keyes says of 
the book that it is an honest exhibit of his views upon all the subjects considered, and, in view 
of his wide experience and unquestioned skill, we commend his book to the notice and study 
of all who work in this field."— *SY. Louis Courier of Medicine. 

11 We do not know of any one work in the English language, devoted to diseases, etc., of 
the genito-urinary organs, including the venereal diseases, that is so well adapted to the wants 
of the general practitioner. To the specialist this book is invaluable." — Virginia Medical 
Monthly. 

" This handsome volume is not merely a new edition of the well-known work of Van Buren 
and Keyes, but a complete revision of that text-book. The original plan of the older work 
has been retained, and its scope remains the same ; but it has been entirely recast, and in a 
large measure rewritten. This course has been made necessary by the vast progress which 
has marked the history of surgery during the last ten years, especially in the field of thera- 

Seutics and operative procedures. To bring the book up abreast of the times upon the new 
evice of litholapaxy, suprapubic cvstotomy, the modern surgery of the kidney, the treat- 
ment now followed in diseases of the tunica vaginalis, and the many minor changes which 
find expression in the use of new agents, Dr. Keyes was compelled to omit many things, to 
add considerable new matter, and largely to modify much of the remainder. Some chapters 
are entirely new, and in order to make' room for desired additions all the cases have been 
dropped. As it now stands, it is a treatise which may safely be consulted, and which fairly 
and freely speaks of the most modern methods. Dr. Keyes'is enthusiastic in his commenda- 
tions of litholapaxy, and cordially indorses the high operation for stone, while he decides 
that the time-honored and brilliant methods of reaching the bladder through the perinseum 
are only applicable in the cases of male children with stones of moderate size. Dr. Keyes 
says the book ' is an honest exhibit of my views upon all the subjects considered ' ; and as his 
experience has been large, and his skill and prudence are undisputed, we have no hesitation 
in say ins: there is no one in this country whose judgment is more worthy of confidence, or 
whose directions may be more safely followed." — American Journal of the Medical Sciences. 



New York: D. APPLETON & CO., 1, 3, & 5 Bond Street. 



THE 

SCIENCE AND AET OF 

MIDWIFERY. 

By WILLIAM THOMPSON LUSK, M. A., M. D., 

Professor of Obstetrics and Diseases of Women and Children in the Bellevue 

Hospital Medical College ; Obstetric Surgeon to the Maternity 

and Emergency Hospitals ; and Gynaecologist 

to the Bellevue Hospital. 



FOURTH EDITION. REVISED AND REWRITTEN. 
With 246 Illustrations. 

8vo. Cloth, $5.00 ; sheep, $6.00. 



" It was the pleasure of the undersigned to write a review of this most 
excellent and masterly work on obstetrics, when it appeared in its first 
edition. The present is the fourth, an edition enlarged and revised. It is 
a model of recent medical literature in obstetrics, and can not but give 
great credit to the author and to American medicine, Model it is of clear, 
forcible, and beautiful English, of good arrangement of subject-matter, and 
of thoroughness of modern obstetric exposition. The changes which have 
taken place in the theory and practice of obstetrics since the issue of the 
last edition have made it necessary for the author to present to the pro- 
fession what is essentially a new book. Most cheerfully will we recommend 
to the students of medicine a study of Lusk. It ranks well with Playfair, 
and is second to no book in our language." — Chauncey D. Palmer, in the 
Ohio Medical Journal. 

"The book is now beyond criticism, for it has been accepted by the un- 
erring judgment of the great body of physicians. We congratulate Dr. 
Lusk upon this reward for the immense labor he has bestoAved upon it." — 
New York Medical Journal. 

"It contains one of the best expositions of the obstetric science and 
practice of the day with which we are acquainted. Throughout the work 
the author shows an intimate acquaintance with the literature of obstet- 
rics, and gives evidence of large practical experience, great discrimination, 
and sound judgment. We heartily recommend the book as a full and clear 
exposition of obstetric science, and safe guide to student and practitioner." 
— London Lancet. 

" It is but a short time since we had occasion to review this work, of 
which we were enabled to speak in the highest terms of praise. The rapid 
advance of many departments of obstetrics has meantime called for a few 
additions. These having been made, it can be confidently said that Lusk's 
Midwifery holds a high place among American authors', and deserves to 
be extensively employed for reference, and recommended to students as 
a reliable and unusually readable text-book." — Canada Medical and 
Surgical Journal. 



New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. 



A Practical Treatise on 
Diseases of the Skin. 

By HENRY G. PIFFARD, A.M., M.D., 

Clinical Professor of Dermatology, University of the City of New York ; Surgeon in Charge 

of the New York Dispensary for Diseases of the Skin; Consulting Surgeon to 

Charity Hospital; Consulting Surgeon to the Bureau of Out-door Belief, 

Bellevue Hospital ; Consulting Dermatologist to the Board of Health, etc. 

With Fifty full-page Original Plates and Thirty-three Illustra- 
tions in the Text. 



Folio form. Sold only by Subscription. 



" The work before us is one of the best yet published for the general prac- 
titioner. The author's name is sufficient to give it authority on any subject 
with which it deals. . . . There are no theoretical or controversial discussions, 
which would serve only to perplex any one but a specialist, and what is necessary 
to be said is put in the most practical manner, and in the fewest possible words. 

"The plan of the work and its execution are both indeed excellent. We 
have seen no work which we can, with so much confidence, recommend to our 
readers, who are in need of help in the diagnosis and treatment of this very im- 
portant class of diseases. The plates and figures are really illustrative of the 
text, are beautifully executed, while the letterpress and binding are all that can 
be desired." — Canada Lancet. 

"... Beyond doubt the most important part of the book is the plates, and 
their excellence and number give it a unique character. Probably photography 
has never before been used so successfully to illustrate diseases of the skin, and 
the excellence of some of the plates in the book is so great as far to surpass any- 
thing of the kind that has as yet come under our observation. . . . Some of the 
plates are a revelation in so. far as they show the extent to which photography 
may be used to depict the clinical appearances of some diseases of the skin. 

"... Dr. Piffard has produced a work which testifies unmistakably to his 
power of observing accurately and of reproducing artistically those appearances 
on which the diagnosis and treatment of skin diseases chiefly depend, while his 
remarks on treatment give evidence of a wide experience in dermatological 
therapeutics." — British Medical Journal. 



New York: D. APPLETON & CO., Publishers, 1, 3, & 5 Bond Street. 



THE PRINCIPLES AND PRACTICE 
OF MEDICLNE. 

Designed for the Use of Practitioners and Students of Medicine. 
By WILLIAM OSLER, M. D., 

Fellow of the Eoyal College of Physicians, London ; Professor of Medicine in the Johns 

Hopkins University, and Physician-in-Chief of the Johns 

Hopkins Hospital, Baltimore. 

SOLD ONLY BY SUBSCRIPTION. 



8vo. Cloth, $5.50 ; sheep, $6.50 ; half morocco, $7.00. 



" By reason of extensive clinical, pathologic, and teaching experience, of exceptional 
opportunity and broad training, and of rare scientific attainments, there are few nen better 
qualified than Dr. Osier to write a work on the Practice of Medicine. Here in Philadelphia, 
where Dr. Osier spent but too few busy years, he will not soon be forgotten ; the impress of 
his work and character will long remain, and the impetus given to careful pathologic study 
and observation will be transmitted through his colleagues, his assistants, and his pupils. 
To say that Dr. Osier has performed his task well, is but to echo the verdict concerning the 
work he has done in the past. If there were one fault of which we would complain, it is 
expressed in the wish that he had said more than he has. Everywhere throughout the work 
one feels the delightful personality of the man. Every page contains evidences of original 
observation, and is marked by an enlightened conservatism. It would be difficult to select 
any one section and say that it is much better than the others. All are conspicuous for their 
comprehensiveness. The descriptions are in places concise, but there are no important 
omissions. Dr. Osier's work needs no special laudation. It speaks for itself. "We most 
heartily commend his ' Practice of Medicine ' to those who desire to be in possession of the 
most recent and best knowledge on the subject with which it has to deal." — Medical News. 

" This volume exhibits originality at the very beginning, inasmuch as there is no preface. 
The author does not take us into his confidence as to his motive for adding another book on 
the 'Principles and Practice of Medicine' to those which have preceded his. He does not 
tell us whether it is because there were too many good ones or too many bad ones ; whether 
the publisher tempted him, or his university demanded it; or whether 'it was simply that he 
had noticed that 'they all do it.' He skips into the public presence without a word but 
with a sort of air which suggests : ' Here I am ! Take me, or leave me, but you had better 
do the former ! > He had probably heard that good wine needs no bush ; and as he has written 
a good book, with an excellent dedication and some sound aphorisms from the Greek on the 
first sheet, it mattered less about his motives. At any rate, after the table of contents and a 
list of charts and illustrations, we find ourselves plunging immediately into typhoid fever, 
which heads Section I (on 'Specific Infectious Diseases') of this royal octavo volume of 
1,080 pages. No preliminaries are devoted to such' abstract subjects as nosology, 
symptomatology, etiology, inflammation, fever, etc. In this respect Osier's hook resembles 
Strumpell's. The style in which Dr. Osier's book is written is clear, concise, and at the 
same time animated. The type is very good. The finish of the paper is excellent, but the 
texture is not strong, and we doubt whether it stands well the strain of the eager student 
who will certainly want to use it often and much, or the inadvertence of the busy practitioner 
who will sometimes consult it hastily. The book has evidently been 'trained down' as 
much as possible to secure handiness without sacrificing even more important essentials. We 
should be glad to be able to think and speak as highly of every medical book presented for 
review as we can of this. In truth, had our enemy written it, we should be unable to find 
much consolation in his commitment."— Boston Medical and Surgical Journal. 



New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. 



A TEEATISE ON 

THE DISEASES OF THE 

NERVOUS SYSTEM. 

By WILLIAM A. HAMMOND, M.D., 

Surgeon-General U. S. Army (retired list). 

With the Collaboration of GRAEME M. HAMMOND, M. D., 

Professor of Diseases of the Mind and Nervous System in the New York 
Post-Graduate Medical School and Hospital, etc. 

With 118 Illustrations. 



8vo. 932 pages. Cloth, $5.00 ; sheep, $6.00. 

" Dr. Hammond's treatise on the diseases of the nervous system is a work which 
has been long familiar to the profession, and has attained a great reputation among 
the standard books for reference. In the preparation of the present edition the 
author has been aided by his son. A vast amount of clinical material is made use 
of, and the results of experimental investigation recorded. The book is written in 
a clear and pleasing style, and obscure conditions are dealt with in a manner which 
will prove of great assistance in the study of this most interesting class of diseases." 
— Canadian Practitioner. 

" Dr. Hammond published the first edition of his ' Treatise on Diseases of the 
Nervous System ' in 1871. It has therefore been before the profession for twenty 
years, and during these years it has continued to grow in public favor, this being 
the ninth edition that has been issued. Appreciation of this work has not only 
been shown in this country, but abroad, as it has been translated into the French, 
the Italian, and the Spanish languages. The present edition has been thoroughly 
revised, and several new chapters added. This is a book of such great value, and is 
referred to so frequently by the medical press and other medical works, that no 
library is complete without it." — Alabama Medical and Surgical Age. 

" There are few books, even upon those subjects which are constantly in the 
ordinary physician's mind, which succeed as has that of Dr. Hammond ; and when 
we recollect that when the first edition of this work appeared, neurology in America 
was in its very infancy, the rapid exhaustion of its editions is the more remarkable. 
In the ninth edition the writer's son has done much toward keeping the work abreast 
of the times, and, with more confidence than ever, it can now be regarded as one of 
the best and most satisfactory works on nervous diseases, either for the practitioner 
or for the advanced student. The book is beautified and its usefulness increased by 
a larger number of illustrations than heretofore— among the best from a medical 
point of view being those representing syringo-myelia, which have been taken from 
the studies of Van Giesen." — Medical News. 



New York : D. APPLETON & CO., 1, 3, & 5 Bond Street. 



THE RULES OF 
ASEPTIC AND ANTISEPTIC SURGERY, 

A PRACTICAL TREATISE FOR THE USE OF STUDENTS 
AND THE GENERAL PRACTITIONER. 

By ARPAD G. GERSTER, M. D., 

PROFESSOR OF SURGERY AT THE NEW YORK POLYCLINIC ; VISITING SURGEON TO THE 
GERMAN HOSPITAL AND TO MOUNT SINAI HOSPITAL, NEW YORK. 

THIRD EDITION, REVISED. 



8vo. Illustrated with Two Hundred and Forty-eight Fine Engravings. 
Cloth, $5.00; sheep, $6.00. 



The attention of the Medical Profession is invited to the following points of 
excellence in this work : 

It deals only with matters of practical interest to, and questions that are 
likely to arise daily in the work of the practicing physician. Its scope is a terse 
yet clear exposition of the principles governing modern operative surgery. It 
enters into the practical details of all the varying conditions of the application 
of the antiseptic method as brought about by emergencies. Every important 
principle is clearly illustrated by citations from actual cases occurring in the 
author's practice. 

It is not intended to take the place of any text-book on surgery, but rather 
to supply a need which exists in every work on the subject in the English Ian. 
guage, by furnishing information on the subject of Asepsis and Antisepsis, with 
which no book on surgery deals to an extent demanded by modern methods. 
It is, in short, a supplement to all surgical text-books. 

The illustrations are typo-gravures, made from photographic negatives taken 
from life, and are marvels of beauty, artistic elegance, and fidelity; each illus- 
tration being a faithful representation, by the camera, of the details of the 
application of all important antiseptic dressings and apparatus, approaching 
nearer to an actual demonstration than has ever before been attempted to be 
done in any medical work. With the exception of a few bacteriological illus- 
trations taken from Koch, Rosenbach, and Bumm, the illustrations are from 
negatives made in the operating-room, and are of a character now for the first 
time employed in a medical work. 



The work has been adopted by the Medical Department of the United States Army. 



New York: D. APPLETON" & CO., Publishers, 1, 3, & 5 Bond Street, 



September, 1892. 

MEDICAL 



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